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UNITED STATES OF AMERICA. 



MODERN GYNECOLOGY 

A TREATISE ON 

DISEASES OF WOMEN 

COMPRISING THE RESULTS OF THE LATEST INVESTIGATIONS AND TREAT- 
MENT IN THIS BRANCH OF 

MEDICAL SCIENCE 

/ 

CHARLES H. TUSHONG, M. D. 

ASSISTANT GYNECOLOGIST TO THE DEMILT DISPENSARY, NEW YORK 
FORMERLY ATTENDING PHYSICIAN TO THE NORTHERN DISPEN- 
SARY, AND ASSISTANT TO THE VANDERBILT CLINIC COL- 
LEGE OF PHYSICIANS AND SURGEONS, NEW YORK 

Ullustrateb 







NEW YORK 

E. B. TREAT, 5 Cooper Union 

1893 






FHce, $2.75 



I^TEODUCTIOK 



The number of books on the diseases of women is already 
large — so large that it may well be a question if the matter 
is not already overdone. A glance at the size and preten- 
sion of these works, however, will show that they are all 
written from one standpoint, that of the specialist. But 
what of the family physician, of the general practitioner ? 
What is being done for him ? This query is especially 
appropriate for the man who graduated twenty, fifteen, ay, 
even ten years ago. When the facilities to-day offered in 
the best medical colleges for acquiring a knowledge of the 
diseases of women are compared with those these men had, 
can we wonder they feel unprepared for this class of work ? 
When they seek to post themselves they are offered a book 
as large as the volume from which they studied the entire 
subject of " Practice of Medicine" when a student. Is it 
surprising that busy men should feel their time inadequate 
for mastering so large a subject? Yet these men are the 
very ones who should know well the essentials of gynecology. 
To the family physician the women of the family naturally 
turn as the friend and adviser on whom they can rely. He 
has been with them during all other forms of illness, and is 

expected to advise them now. The older women have been 

5 



6 INTRODUCTION. 

attended in confinements by this physician, and feel they 
can go to him without reserve. They are particularly disin- 
clined to go to a stranger for advice concerning the diseases 
peculiar to their sex. The delicacy women naturally feel 
about alluding to their sexual organs is less in speaking to 
the man who has been present at the bedside when their 
children were born, and who has also attended those children 
in all their illnesses. The younger females of the family go 
to him more readily for the same reason — he is a kind friend 
and adviser in whom they can trust. 

Then to whom else shall the women go ? It is only in the 
larger cities that specialists are easily accessible. Even when 
near at hand, he is a stranger, he has not the knowledge of 
the medical history of the entire family already known from 
long years of observation by their family physician. 

In addition to the above reasons for first consulting the 
general practitioner is the additional one that women are 
only beginning to learn that they can receive relief. The 
past generation of women were taught to suffer in silence, 
and their daughters have learned much of the same stoicism 
from them. The non-medical part of a community is always 
behind its medical men. They are expected to enlighten it 
on subjects of this nature. Some women have just learned 
from a more progressive physician that suffering is not 
woman's necessary lot. These tell others, and as a result 
they are all seeking relief. If the family physician cannot 
give it, some will be content to suffer on, the rest will go for 
advice elsewhere. 

The general practitioner should be competent to give these 
women the advice asked. There is nothing in the routine work 



INTRODUCTION. 7 

of gynecology requiring more skill than a case in General 
Medicine. The instruments and appliances are few, and a 
knowledge of their use is readily acquired. It is essential to 
acquire dexterity in making examinations to the same extent 
that a knowledge of how to examine a heart or the lungs is 
essential. This dexterity can only come with much practice. 
The sense of touch can only be educated by many trials. In 
the same way the use of the speculum, sound, tenaculum, 
and applicators must be learned. These manipulations are 
not many nor complicated, and are easily mastered. 

The effort of this book is to place before the physician 
a clear, common-sense statement of the symptoms of the 
various diseases of the female sexual organs; to indicate 
in detail the methods of treatment that can be applied by 
him, and also to indicate in brief the methods requiring the 
aid of a specially trained consultant of larger experience. 
It is as important to be able to appreciate the need of a 
major operation requiring a surgeon's help as it is to know 
the proper remedy to apply where special advice is not 
required. How many cases of cancer of the cervix might 
be cured if the physician first consulted knew the impor- 
tance of the symptoms and acted promptly in having it 
removed ! If one woman is saved so horrible a death I shall 
not have written in vain. 

In preparing this volume no effort has been spared to 
make it complete and comprehensive. Many of the illustra- 
tions have been made from photographs taken specially for 
it. Others have been drawn by an artist under the imme- 
diate supervision of the author, and all have been executed 
with every attention to detail and correctness available. 



S INTRODUCTION. 

I am indebted for valuable suggestions and the observa- 
tions of cases to Dr. F. LeRoy Satterlee, Dr. Paul Outer- 
bridge, Dr. John Woodman, and Dr. Robert J. Devlin, of 
New York, and Dr. J. W. Houston, of Oxford, Pa., and desire 
to express my appreciation of their assistance at this time. 

C. H. Bushong, M.D. 

No. 59 West Nineteenth Street, 
New York, March, 1893. 



CONTENTS. 



CHAPTER I. 



Examinations. — Oral — Physical — Positions — Dorsal — Sims' — The 
Genu-Pectoral — The External Genitalia — The Digital Exami- 
nation — Bimanual Examining — Examination of Single Women 
— The Speculum and its Uses — Sims' Speculum — Self -retaining 
Specula 17 

CHAPTER II. 

Menstruation. — Normal — Puberty — Menstrual Abnormalities — 
Dysmenorrhea — Uterine Neuroses and Eruptions — Vicarious 
Menstruation 48 



CHAPTER HI. 

Amenorrhea. — Primitive or Acquired — Causes — Pregnancy — Anae- 
mia — From Plethora — Hyper-involution — Castration — Meno- 
pause 61 

CHAPTER IV. 

Scanty Menstruation. — Treatment — Douches — Applications — 

Tampons — Leeches ,..,..,..,..... 9§ 

9 



10 CONTENTS. 

CHAPTER V. 

Menorrhagia and Metrorrhagia. — Uterine Hemorrhage — Causes 
— Immediate Control by Packing the Vagina — Intra-uterine 
Applications — Drugs for Hemorrhage — After-treatment for 
Menorrhagia — Metrorrhagia — Dilatation of Cervix for Exami- 
nation — With Tents — With Divulsors — Treatment of Metror- 
rhagia 114 

CHAPTER VI. 

Diseases of the Vulva. — Vulvitis in Children — Pruritis Vulvae — 

Inflammation of the Vulvar Glands 147 



CHAPTER VII. 

The Urethra and Urinary Meatus. — Prolapse of the Urethra — 

Symptoms — Treatment — Urethritis — Cystitis 157 



CHAPTER VIII. 

Diseases of the Vagina. — The Normal Vagina — Atresia — Imper- 
forate Hymen — Retention of Menstrual Blood — Constrictions 
— Vaginismus — Vaginitis — Gonorrhoea in the Female — Acute 
Vaginitis — Chronic Vaginitis — Treatment 164 

CHAPTER IX. 

The Cervix. — Stenosis — Treatment — Uterine Stems — Atrophy of 
Cervix— Hypertrophy 183 



CONTENTS. 11 

CHAPTER X. 

Metritis. — Causes of — Symptoms — Corporeal — Cervical — Lacera- 
tion of Cervix — Membranous Metritis — Uterine Syndronia — 
Examination for Metritis — Treatment 197 

CHAPTER XL 

Uterine Displacements. — Causes — Symptoms — Diagnosis — Tlie 
Normal Position — Anteversion — Anteflexion — Dysmenorrhea 
— Sterility — Examination — Directions for L"se of the Sound — 
Tampons — Methods of Retaining the Restored Position — Re- 
troversion — Retroflexion — Methods of Reducing — Uterine Mas- 
sage — Repositors — Pessaries — Operations for Retroflexion — 
Mollites Uteri — Prolapse of the Genital Organs — The Perineum 
— Rectocele — Cystocele — Treatment 227 

CHAPTER XII. 

Salpingitis and Peri-salpingitis. — Purulent and Non-purulent — 
Varieties — Symptoms — Sequela? — Salpinx — Treatment — Peri- 
salpingitis — Pelvic Peritonitis — Symptoms — Treatment 292 

CHAPTER XIII. 

Ovaries. — Diseases of — Congestion — Oophoritis — Acute — Chronic 
— Neoplasms 313 

CHAPTER XTV. 

Fibroma.— Positions and Symptoms of— Abdominal Fibromata — 
Treatment by Drugs— By Electricity— Operations for— Curette- 
ment— Ligating of the Uterine Arteries— Castration, , , , 327 



12 CONTENTS. 

CHAPTER XV. 

Carcinoma. — Position and Course of — Early and General Symp- 
toms — Treatment — Surgical — Medicinal — Palliative Treatment 
to Prolong Life — Internal Remedies — Electricity 340 

CHAPTER XVI. 

Hematocele. — Intra- and Extra-peritoneal — Symptoms — Treat- 
ment 352 

CHAPTER XVII. 

Sterility. — Causes of — Due to the Male — To the Female — Treat- 
ment—To Both 357 

APPENDIX. 
Instruments and Office Appliances 363 

General Index 377 



ILLTTSTBATIONS. 



Fig. 1. Dorsal-recumbent Position 21 

Fig. 2. Sims' Position seen from in Front 22 

Fig. 3. Genu-pectoral Position 23 

Fig. 4. Separation of Labia Majora and Buttocks for Inspection of 

External Genitalia 25 

Fig. 5. Position of Hand usually advised for Examinations 27 

Fig. 6. Improved Position advised by Davenport 28 

Fig. 7. Correct Position of the Hand in making Examinations. ... 28 
Fig. 8. Posterior Vaginal Wall pushed into View by Finger in the 

Rectum 30 

Fig. 9. Examination of the Rectal Mucous Membrane turned out 

by Fingers in the Vagina. (Munde.) 31 

Fig. 10. Outline View of Bimanual Examination. (Davenport. ) . . 32 

Fig. 11. Bimanual Examination. (Pozzi.) 33 

Fig. 12. Bivalve Speculum in Position 39 

Fig. 13. Sims' Speculum 40 

Fig. 14. Manner of Holding Sims' Speculum when Introducing 40 

Fig. 15. Sims' Depressor for Anterior Vaginal Wall 41 

Fig. 16. Hunter's Depressor 41 

Fig. 17. Sims' Method of Holding Sims' Speculum 42 

Fig. 18. Munde's Method of Holding Sims' Speculum 42 

Fig. 19. Relative Positions of Patient, Physician, and Nurse when 

using Sims' Position. (Sims. ) 43 

Fig. 20. Cleveland's Speculum 44 

Fig. 21. Cleveland's Speculum 44 

Fig. 22. Belt and Strap for Holding Cleveland's Speculum 45 

13 



14 ILLUSTRATIONS. 

Fig. 23. Patient in Sims' Position with Cleveland's Speculum in 

Position 47 

Fig. 24. Reynolds' Tank and Tubing for Douches 98 

Fig. 25. Reynolds' Bed-pan with Siphon Attachment 103 

Fig. 26. Reese's Uterine Leech 112 

Fig. 27. Straight Sponge Tent, Hollow 136 

Fig. 28. Curved Sponge Tent 137 

Fig. 29. Laminaria Tent 137 

Fig. 30. Tupelo Tents 138 

Fig. 31. Skene's Tenaculum Forceps 140 

Fig. 32. Ellinger's Rapid Divulsors 142 

Fig. 33. Bozeman's Dressing Forceps 143 

Fig. 34. Thomas' Wire Curette 144 

Fig. 35. Emmet's Urethral Button-hole Scissors 159 

Fig. 36. Correct Position of the Pelvic Organs 165 

Fig. 37. Imperforate Hymen, Vagina Largely Distended 166 

Fig. 38. Vaginal Tube, Glass 171 

Fig. 39. Bozeman's Vaginal Dilator 173 

Fig. 40. Bozeman's Vaginal Dilator 173 

Fig. 41. Hank's Uterine Dilator 187 

Fig. 42. Set of Peaslee's Uterine Dilators 187 

Fig. 43. Wylie's Uterine Dilator 188 

Fig. 44. Sims' Uterine Dilator 188 

Fig. 45. Barnes' Dilators, Three Sizes 190 

Fig. 46. Outerbridge's Introducer for his Drain 192 

Fig. 47. Method of Grasping Drain with Dressing Forceps for In- 
troduction 192 

Fig. 48. Outerbridge's Drain in Position 193 

Fig. 49. Hypertrophy of the Cervix 204 

Fig. 50. Outerbridge Drain used for Drainage 217 

Fig. 51. Uterine Applicator 219 

Fig. 52. Method of Wrapping the Uterine Applicator 219 

Fig. 53. The Applicator Wrapped for Use 219 

Fig. 54. Normal Position of the Uterus in the Pelvis 228 

Fig. 55. Position of Uterus in Ante version 229 



ILLUSTRATIONS. 15 

Fig. 56. Thomas' Anteversion Pessary 232 

Fig. 57. Thomas' Anteversion Pessary in Position 232 

Fig. 58. Thomas' Anteversion Pessary, Other Forms 233 

Fig. 59. Anteflexion of the Uterine Body 239 

Fig. 60. Simpson's Uterine Sound 243 

Fig. 61. Hunter's Uterine Sound 243 

Fig. 62. Sound in Normal Uterus 245 

Fig. 63. Tenaculum with Angular Point 246 

Fig. 64. Tenaculum with Curved Point 246 

Fig. 65. First and Second Steps in Passing a Sound 247 

Fig. 66. Third Step in Passing a Sound 248 

Fig. 67. Uterine Probe, Wyeth's 250 

Fig. 68. Graily Hewitt's Pessary 253 

Fig. 69. Thomas' Uterine Stem and Pessary 254 

Fig. 70. Outerbridge's Wire Drain 256 

Fig. 71. Outerbridge's Wire Drain bent to fit Curve in Uterus 256 

Fig. 72. Anteflexion of the Body relieved by Outerbridge Drain. . . 257 
Fig. 73. Anteflexion of both the Body and the Neck relieved by 

Outerbridge Drain 257 

Fig. 74. Discission for Extreme Anteflexion 258 

Fig. 75. Retroversion, Third Degree 259 

Fig. 76. Thomas-Hewitt Retroversion Pessary 261 

Fig. 77. Retroversion before Restoration 261 

Fig. 78. Retroversion corrected by Genu -pectoral Position 262 

Fig. 79. Retroflexion 263 

Fig. 80. Jennison's Repositor 269 

Fig. 81. Flexible Metal Ring covered with Rubber 271 

Fig. 82. Emmet-Smith Pessary 272 

Fig. 83. Inflated Ring Pessary 273 

Fig. 84. Hoffman's Pessary 273 

Fig. 85. Introduction of Pessary, First Step 275 

Fig. 86. Introduction of Pessary, Second Step 276 

Fig. 87. Introduction of Pessary, Third Step 276 

Fig. 88. Perineal Body as a Support of the Parturient Canal 281 

Fig. 89. Inversion 283 



16 ILLUSTRATIONS. 

Fig. 90. Mucous Fibroid at Fundus Simulating Inversion 285 

Fig. 91. Fibroid at Cervix Simulating Inversion 285 

Fig. 92. White's Method of Reducing an Inverted Uterus 288 

Fig. 93. Polyp with Long Narrow Pedicle 327 

Fig. 94. Polyp with Broad Base 328 

Fig. 95. Multiple Intra-mural Fibromata. (Martin.) 336 

Fig. 96. Sharp Curette (Sims') 337 

Fig. 97. Dr. Woodman's Case, Cancer of Vulva 343 

Fig. 98. Outerbridge's Drain for Sterility 360 

Fig. 99. Gynecological Table 364 

Fig. 100. Instrument Cabinet 365 

Fig. 101. Brewer's Speculum 370 

Fig. 102. Graves' Speculum 371 

Fig. 103. Dawson's Modification of Sims' Speculum 372 

Fig. 104. Munde's Modification of Sims' Speculum 372 

Fig. 105. Dressing Forceps 373 



MODERN GYNECOLOGY. 



CHAPTER I. 



EXAMINATIONS 



The first information in regard to her condition is ob- 
tained from the patient herself, and consists of an historical 
account of her past life and a description of her present 
symptoms. This information is obtained partly by allowing 
the patient to tell her own story and partly in answer to 
questions asked her by the physician. 

The Oral Examination. — Many patients tell a clear, 
straightforward story, and can be trusted to give their own 
history with but little in the way of questioning, while 
others will ramble on aimlessly, talking about trivialities 
which only confuse and lead nowhere. In no department 
of medicine will the physician's tact be called upon more 
frequently than in the endeavor to obtain a definite history 
of some obtuse patient's gynecological past life. 

A good beginning in inquiring concerning her history is 

to ask her age and civil condition — that is, if she is single, 

married, or widowed. It is important to know at what age 

she began to menstruate, and the presence or absence of any 

17 



18 MODERN GYNECOLOGY. 

abnormalities about the flow, its quantity, regularity, and 
duration, both during the first months and after. The 
amount of pain should be told, the number of days the flow 
lasts at each period, and the duration of time between each 
menstruation. 

If she has been married, the number of children must be 
asked, and it is well to know the date of the birth of the 
first and last. Information regarding the character of the 
labors will naturally follow, and if the deliveries were with 
the aid of instruments or not. If she has had miscarriages, 
the period of gestation at which they occurred and the cause 
in each case are important. Inquiry should be made if chil- 
dren have been born at full term since the last abortion. If 
she has had children since the last abortion, it is important 
to know how long they have lived and if in good health. If 
dead, the cause of death will give light on the subject. This 
information may give an intimation as to the presence of 
syphilis or tubercular disease in mother or fetus. 

It is advisable to try and learn if the patient has suffered 
from attacks of any kind of pelvic disease, and especially if 
she has had a pelvic peritonitis. This the physician must 
learn by her description of the symptoms and not by her 
simple statement, as women frequently have erroneous no- 
tions in this respect. 

The condition at the present time requires investigation 
next, and it will be discovered if she is menstruating or not, 
or if she is pregnant, and if so, the probable date of concep- 
tion. She should always be asked if she has leucorrhcea 
and its amount and character, and if it is more immediately 
before or after the menstrual flow. 



EXAMINATIONS. 19 

The importance of learning the trne state of the alimentary 
canal must be remembered. Constipation is the bane of civ- 
ilized woman, causing many of her ills. All the resulting 
aches, pains, and indigestions are so common as only to need 
mention to reveal their importance. 

The condition of the bladder is at times of special impor- 
tance to the gynecologist in making a diagnosis, dysuria and 
incontinence being frequently the result of pressure from 
the genital organs. 

In the case of young girls and unmarried women the 
duties of the physician require much delicacy and care. 
The patient should always be accompanied by her mother 
or some married woman, and the inquiries can at times be 
made through her. She will usually come because of some 
abnormality about her menstruation, and the companion 
will generally have been informed of the main symptoms 
beforehand. If such is not the case, the questions must be 
put in such a way as to allow her to tell her story as briefly 
as is possible and at the same time furnish full information 
for the diagnosis. Anything calculated to shock her sensi- 
bilities should be carefully avoided. 

The Physical Examination. — Many pelvic diseases re- 
semble each other in symptoms to such an extent that a 
diagnosis can rarely be made without a physical examina- 
tion. The object of the verbal examination is more to 
establish the probability of any disease in the pelvis than 
to learn its character. The symptoms complained of are 
often invaluable as aids in making the differential diagnosis 
in conjunction with the physical signs found on examina- 
tion. It is consequently essential to both physician and 



20 MODERN GYNECOLOGY. 

patient that the physical examination be as thorough as it 
can be made. At the same time it is important that the 
discomfort of the patient should be reduced to a minimum. 
Consequently every general physician should have in his 
office the facilities for examining the pelvic organs of the 
female. The first desideratum for the convenience of both 
is an examining chair or table. There are many good ones 
in the market, the more elaborate being expensive. It will 
be found that the simplest are the most convenient and 
durable. 

The Examining Table. — A table four feet long, two and 
a half feet high, and twenty-seven inches wide, is all that is 
absolutely needed. The foot-rest may be the ordinary iron 
stirrup to rest the heel in, and should be so arranged that it 
can be readily removed when the table is to be used for 
other than the dorsal position. Many tables do not have a 
stirrup at all, the heels simply resting on the table. It is 
convenient at times to have the table feet adjustable, mak- 
ing it possible to raise the one end higher than the other. 
This can usually be cheaply arranged. 

Most tables are covered with leather, and padded to make 
them more comfortable ; a small leather-covered pillow also 
adds to the patient's comfort. Very stout women he more 
comfortably if a head-rest is provided that is higher than 
the ordinary pillow. 

A sheet or mantle is also needed to cover the patient 
while on the table, and should be placed so as to save her 
from exposure of her person as far as possible. It can be 
held in front of her while she raises her clothing in getting 
on the table, and after she is there she should be arranged 



EXAMINATIONS. 



21 



under this covering, and all examinations and treatment 
should be done with the sheet so arranged about her as to 
expose none of her person or underclothing that is not abso- 
lutely necessary. 

Positions on the Table. — The positions on the table of 
chief importance to the minor gynecologist are three : the 
dorsal, the Sims, and the genu-pectoral. 

The Dorsal Position (Fig. 1) is most used in the United 
States, and is most convenient for both patient and physician. 
The patient lies prone, with the hips as near the end of the 




Fig. 1. The Dorsal-Recumbent Position. (From photograph, expressly for 
this work.) 

table as possible ; her heels are placed as near the buttocks 
as is comfortable and held there by a stirrup, the knees 
being widely separated. She will appreciate the delicacy 
which prompts the examiner who wraps a sheet around her 
in such a manner as to completely cover each leg down to, 
and including, the foot. 

A thorough and searching digital examination can only 



22 



MODERN GYNECOLOGY. 



be made when the hips are well down to the end of the 
table. The nse of the bivalve speculum is also much more 
satisfactory when this simple precaution is taken. In mak- 
ing first examinations it often requires some patience to get 
the patient to understand what is required of her. 

The Sims Position (Fig. 2) is less used by the general 
practitioner because, until recently, it required the service 
of a nurse or assistant to hold Sims speculum. In this 




Fig. 2. The Sims Position. (From photograph, expressly for this work.) 



position the patient is placed on her left side with the left 
arm and shoulder drawn back. The left side of the face 
and chest is in contact with the table. The right shoulder 
is bent over forward as near to the table as is possible with- 
out turning the hips, the knees are then drawn up toward 
the chin, the right or upper leg being more bent than the 
left or under one. The corset and all tight clothing must 
be removed from about the waist, leaving the abdominal 
walls entirely free. The result is that in this position the 



EXAMINATIONS. 



23 



tendency of the pelvic organs is toward the diaphragm. 
They are consequently more difficult to reach by the exam- 
ining finger, yet the advantages of this position are many 
and it is frequently used. It is especially convenient for 
operations through the vagina where, the patient being 
under an anaesthetic, two assistants would be required to 
hold the knees if she were in the dorsal position. The ease 
with which the uterus can be drawn down by drawing on 
the cervix with a tenaculum makes it easily accessible for 
operations. 

The Genu-pectoral Position (Fig. 3) is indicated by its name. 
The patient kneels on the table with her chest on the same 
level, the face being turned aside ; the hips are thus elevated 
above the shoulders, consequently the position can be used 
to cause gravity to assist in replacing flexions and versions 




Fig. 3. The Genu-pectoral Position. 

of the uterus and some forms of prolapse of the pelvic 
organs. It is also convenient when it is desired to pack the 
vagina very tightly with tampons. Entire freedom of the 
waist and abdominal walls from all restraint is necessary 



24 MODERN GYNECOLOGY. 

before assuming the knee-chest position. Figure 3 shows 
the knee-chest position and the tendency of the abdominal 
viscera toward the diaphragm. 

The physician will succeed with his pelvic cases who can 
make an examination with delicacy and gentleness yet with 
sufficient thoroughness to obtain all the information re- 
quired. Mention of some of the necessary details in making 
examinations will not come amiss here. 

The External Examination. — After the patient is cor- 
rectly placed on the table the examination should be made 
in the following order : examination of external organs, dig- 
ital examination, and examination with specula. 

Inspection of the External Genitals. — The first step in ex- 
amining the genital organs of a woman is inspection of the 
external genitalia. This is usually done with the patient in 
the dorsal recumbent position, the examiner sitting between 
her feet. The labia majora can be seen as far as their 
cutaneous surfaces extend. The labia minora at times are 
developed largely and extend out between the greater labia. 
The condition of the mons veneris can be noted, parasites 
being looked for, and the perineum and anus are in full 
view. After these external parts have been thoroughly in- 
spected the labia majora can be separated, each being drawn 
aside by a small piece of cotton held between the thumb and 
index finger of the hand most convenient to it. This ex- 
poses the whole of the external genitalia to view (see Fig. 4). 
The clitoris with its prepuce is seen above with the labia 
minora partially inclosing it as they unite just below it and 
gradually diverging as they pass backward. Between them 
is the vestibule with the urethral orifice near the middle 



EXAMINATIONS. 



25 



of its lower margin. Next below the vestibule is the 
opening to the vagina, more or less closed by the hymen 
when present, or surrounded by its remnants when it has 
been ruptured. If the hymen has completely disappeared 
the caftinclse myrtifornies may be present, in which case 



■^ %$: 




Fig. 4. Separation of Labia and Bnttocks. (From photograph, expressly for 

this work.) 

they may be seen surrounding the entrance to the vagina 
just above the point at which the hymen is attached, when 
present. If the labia majora are widely separated the fossa 
navicularis can be seen at the posterior edge of the vaginal 
opening, and. the condition of the perineum can be inspected 
at the same time. 

Inspection of tlie Anal Region. — Pressure with the examin- 
er's thumbs against the buttocks will separate them and 
enable him to see the condition of the anus (see Fig. 4), 



26 MODERN GYNECOLOGY. 

revealing the presence or absence of prolapsus, piles, or con- 
gested vessels there. Ulcers about the amis will also be 
seen. 

While many words are required to describe all these 
things, the examination necessary to learn all that is re- 
quired can be made in a very few seconds. It is important 
to know if ulceration, parasites, or filth are present on or 
around the external genitals before making an examination 
of the vagina, as a matter of self -protection for the exam- 
iner, if for no other reason. 

When an examination of the pelvic organs is to be made 
through the vagina, the position and preparation of the 
patient on the table are first attended to as has been out- 
lined in describing the positions on the table, care being 
taken to protect her as much as possible from exposure of 
her person. The examiner should not be abrupt in his 
approach to the sexual organs and yet should use sufficient 
despatch to avoid prolonged manipulations or tiresome waits 
in cramped positions. 

The Digital Examination. — Everything being ready for 
a digital examination, the preparation and position of the 
hand used in examining is next considered. The first point 
is which hand to use. The majority of physicians use the 
right hand for the same reason that they employ this hand 
to write, etc., because they can use it more readily. Some 
instructors in gynecology, however, have advised the use of 
the left hand for a number of reasons, the chief one being 
that it leaves free the stronger right hand to be used in 
depressing the abdominal wall in making bimanual exami- 
nations. It is better to educate both hands and thus be 



EXAMINATIONS. 27 

enabled to use either in case of emergency. A cut on the 
finger or other cause may make it advisable not to use an 
injured hand. Another reason for using both hands is that 
at times more definite information can be obtained by ex : 
amining either side of the uterus and the lateral fornix with. 
that finger which will allow the palmar surface of the finger 
to rest against the uterine wall. The greater acuteness of 
the sensations from the palmar surface of the finger insures 
more definite information from its use than can be obtained 
by depending upon the back of the finger with its nail and 
less sensitive cuticle. 

The Position of the Hand in making examinations is of 
importance. The position usually advised is not the one 
calculated to gain the greatest amount of information, nor 
is it the most comfortable to the patient. Most examiners 
require to add to the distance they can reach with the finger 
by depressing the perine- 
um and pushing it upward 
as far as possible. If this 
is attempted with the ex- 
ternal fingers flexed into 
the palm, as is usually ad- 
vised (Fig. 5), the distance 
gained is not great, and 

,-, j. .-,, , . Fig. 5. Position of Hand usually advised. 

the patient will complain 

of the discomfort caused by the knuckles of the middle and 
ring fingers. These fingers should not be entirely closed, 
neither should they be entirely extended, as is shown in this 
outline (Fig. 6), but they should be held in a partially flexed 
condition, as shown in Figure 7. To be exact, the chord of 




28 



MODERN GYNECOLOGY. 




the curve of the external fingers should make an angle of 

about forty-five degrees with the line of the index finger. 

In this position the hand is introduced under the cover- 
ing, the index finger having been anointed with vaseline or 

some other lubricant. 
The index finger should 
be flexed into the palm 
of the hand until the 
perineum is reached, to 
prevent soiling the un- 
derclothing of the pa- 
tient in all examinations 
where she is not thor- 
oughly protected by a 
sheet. 

When the perineum is 

touched by the knuckle the index finger is extended, its point 

pressed against the perineum and allowed to pass forward 

until it slips between the 

labia majora into the 

vagina. As soon as the 

finger enters the vagina, 

pressure should be made 

by its side against the 

perineal body, depressing 

it in the direction of the 

tip of the coccyx as the 

finger passes up toward 

the cervix. When the web between the index and middle 

fingers reaches the perineum, that part is carried still further 



Fig. 6. Position of Hand advised by 
Davenport. 




Fig. 7. Correct Position of Hand. 



EXAMINATIONS. 29 

upward by it, enabling the examining finger to reach far up 
at the side of the uterus, behind it or in front between it and 
the bladder. The middle finger will lie in the crease between 
the buttocks, which is depressed with the perineum, so that 
the external fingers are not in the same plane with the index 
finger. The angle of divergence between the index and the 
other fingers varies, of course, as the finger within the vagina 
passes to one side or the other of the cervix. 

The Use of Ttvo Fingers per Vaginnm. — Some examiners 
advise the introduction of two fingers into the vagina. This 
is a custom not to be recommended in routine practice. Like 
the bimanual method of examining, it has its uses, but is 
not required except when indicated by special conditions. 

It is painful to many women to have two fingers thrust 
into the vagina, and even multipara with large, roomy pelves 
complain of discomfort. The impression gained as to size, 
shape, and consistency is not more definite with two fingers 
than with one, as two impressions will at times confuse the 
examiner and leave an uncertainty in his mind until one 
finger is removed and the index finger gives its conclusive 
report. 

When there is doubt as to whether a mass is movable 
with the uterus or not, it may give information to introduce 
the middle finger behind the cervix and hold it in contact 
with the tumor or fundus in Douglas' pouch while the index 
finger makes pressure on the anterior side of the cervix. 
The same maneuver is also used to start the retroflexed 
fundus upward as the first movement toward its reposition. 
In usual routine cases the 'index finger will give all the in- 
formation obtainable with least inconvenience to the patient. 



30 



MODERN GYNECOLOGY. 



Examination per Rectum. — Where additional information 
is needed it may be advisable to explore the rectum. This 
is done with the index finger prepared as for vaginal exam- 
ination and held in about the same position. The tip of the 
finger is introduced through the anal ring very slowly and 
gently in order to give the sphincters time to relax. If the 
patient will "bear down" slightly the entrance is more eas- 
ily effected. 

The finger in the rectum can be passed higher in the pel- 
vis than in the vaginal, and more definite information re- 




Eversion of Posterior Vaginal Wall, with Finger in the Rectum. 
(From photograph, expressly for this work.) 

garding the condition and position of the posterior of the 
uterus can be obtained. The position and size of the ova- 
ries and tubes can be better learned per rectum, also the con- 
dition of the utero-sacral and the broad ligaments. 

Occasionally it is of advantage to introduce the middle 



EXAMINATIONS. 31 

finger into the rectum and the index finger in the vagina at 
the same time. This is not often necessary, but is at times 
required. 

Inspection of Posterior Wall of the Vagina. — When it is 
required to inspect the posterior vaginal wall a finger is in- 
troduced into the rectum until its tip passes the sphincters. 
It is then pressed forward, everting the lower part of the 
posterior vaginal wall, exposing it to view. The labia are 
separated to give a clearer view by pressing the one to the 
examiner's right with the right thumb (the right index finger 




Fig. 9. Digital Eversion of the Rectum. (Munde.) 

being in the rectum), the other labia being held aside by 
the index finger of the left hand. In this manner the pos- 
terior vaginal wall can be inspected a considerable distance 
upward unless the perineum is very resistant. A photo- 
graph of this position is shown in Figure 8. 

Inspection of Mucous Membrane of the Rectum. — By a re- 
versal of the above-described process the interior of the 
rectum can also be examined, two fingers depressing the 
posterior vaginal wall and everting the rectum (Fig. 9). In 
either of these maneuvers care must be taken when the sep- 



32 MODERN GYNECOLOGY. 

turn is thin between the rectum and vagina or the ends of the 
fingers may break through, making a recto-vaginal fistula. 

Bimanual Examinations. — A bimanual examination is 
occasionally required to give more information of the pelvic 
contents than can be obtained by examination through the 
vagina and rectum. The method of making such examina- 
tion is simple. The index finger of one hand is introduced 




Fig. 10. Relative Position of Hands in Bimanual Examinations. (Davenport. ) 

into the vagina as in making a digital examination, and the 
other hand is placed on the abdomen just above the sym- 
physis pubes. This hand rests with its palmar surface 
against the abdominal wall, the fingers being partially 
flexed. Pressure is made gently but firmly against the 
abdominal muscles, depressing them just above the pelvic 
brim until the fingers sink into the pelvis. The depression 



EXAMINATIONS. 



33 



can be made deeper and more quickly if the greatest force 
is used while the patient makes a deep expiration, slightly 
relaxing the pressure during inspiration. Figure 10 shows 
in outline the relative positions of hands and pelvic organs 




Fig. 11. Bimamual Ex am ination (Pozzi). 

when making a bimanual examination. Figure 11 is a pho- 
tograph of position of hands in making a bimanual exam- 
ination. 

The Object of the hand on the abdomen is to depress the 
pelvic organs and bring them down in the reach of the 
finger within the vagina. The size and consistency of the 
uterus, the ovaries, or a pelvic tumor can be made out by 
getting it between the hands in this bimanual method. 
When it is desirable to g^et a finger into the uterine cavity 
counter-pressure on the fundus with the hand on the abdo- 
men will be of assistance. The uterus is forced down over 



34 MODERN GYNECOLOGY. 

the finger in the vagina and pressure upward on its liga- 
ments and other attachments is avoided. The hand on the 
abdomen can frequently render valuable assistance in repo- 
sition of uterine displacements or in restoring an inversion. 

Some examiners use the bimanual method as a part of 
each pelvic examination. This is unnecessary, as a perfect 
knowledge of the true position and condition of the impor- 
tant organs in the pelvis can be obtained without it, except in 
a few special cases. The hand on the abdomen is not pleas- 
ant to the patient, the pressure exerted often causing pain. 
If the abdominal walls are thick or rigid much pressure 
must be used to get the hand depressed enough to be of any 
assistance. If the patient is nervous it may be impossible 
for her to relax the abdominal muscles sufficiently to allow 
any depression above the symphysis. In addition to the 
above objections to a bimanual examination as a matter of 
routine is the fact that the pressure of the hand above 
pushes the organs toward the pelvic outlet and changes their 
position in the pelvis and in relation to each other, thus giv- 
ing the examiner a false impression in regard to them. 

The aid of the hand on the abdomen is required in cases 
of enlargement of the uterus from pregnancy (where the 
probable age of the fetus is to be ascertained) or from any 
other cause. It is also of assistance in locating the size and 
consistency of tumors in some cases of ovarian disease when 
those organs are not displaced, and rarely it is needed in 
uterine displacements. 

Considerable practice is required to enable an examiner to 
make a diagnosis from an examination made with the finger 
in the vagina only, but many of the most reliable diagnos- 



EXAMINATIONS. 35 

ticians make very few bimanual examinations. The more 
accurately the examining finger is trained, the nearer it 
comes to being ample for all but the rarest contingencies. 

Digital Examination in Sims' Position. — The directions for 
making a digital examination have all been given, suppos- 
ing the patient to be in the dorsal position. A like exam- 
ination can be made with her in Sims' position. The right 
hand is used and the position of the fingers changed so as 
to occupy the same position in relation to the patient as 
when she is in the dorsal position. . 

By reaching the left hand forward above the thighs to the 
abdomen a bimanual examination can be made while the 
patient is in this position also. 

Digital Examination in Genu-pectoral Position. — Digital 
examination is not often made with the patient in the knee- 
chest position, but when indicated it can be made with little 
difficulty. When this position is taken for diagnostic pur- 
pose the perineum is elevated either by the fingers or a 
Sims speculum; but as it is a tiresome position for the 
patient to keep for any length of time, it is best to have her 
change to the Sims or dorsal position as soon as possible. 

Examinations through tlie Urethra and Bladder. — Cases 
rarely occur in which it is necessary to introduce a finger 
into the bladder in making examinations. In cases of atre- 
sia or entire absence of the vagina, one finger in the blad- 
der and another in the rectum will enable the presence or 
absence of the uterus and its appendages to be demon- 
strated. In order to use this method the urethra must first 
be dilated with graduated sounds to admit the finger, care 
being necessary to avoid rupture of the sphincter vesica? and 



36 MODERN GYNECOLOGY. 

thus causing incontinence of urine. When for any reason 
an examination of the ureters is required the urethra is 
made to admit the finger in the same way. The index 
finger with a catheter or sound along its palmar surface is 
passed into the bladder, the trigone is found by the sense of 
touch and the instrument guided into each ureter. This 
operation is too seldom required to call for further descrip- 
tion here. 

Examinations with the Patient Standing. — Examinations are 
at times made with the patient standing. The examination 
is thus made to ascertain the presence and amount of pro- 
lapse present, the organs returning more or less to a normal 
position when the patient is reclining. When about to ex- 
amine a patient in the erect position she is instructed to 
place one foot on a stool or low chair and the physician 
kneels on one knee before her. The hand is then intro- 
duced beneath the clothing and the index finger inserted 
into the vagina. The position of the cervix and fundus are 
first noted, after which the patient is requested to strain 
down in order to learn the degree of relaxation of the uter- 
ine attachments. 

Examination of Single Women. — The sexual organs of 
single women should not be examined unless the indica- 
tions for it are strong; this is especially true of young 
girls. No feelings of modesty should prevent the physician 
from advising an examination when it is needed in order to 
clear up a diagnosis, but unless the symptoms are urgent no 
great harm will result from an effort to cure the patient 
without an examination. Internal remedies will relieve 
some pelvic conditions and certainly merit a trial before 



EXAMINATIONS. 37 

subjecting a young girl to the ordeal of being examined. 
Her amenorrhcea and leucorrhoea are likewise frequently 
results of nial-conditions of the general system which in- 
ternal medication will remove. When general treatment is 
begun the mother should be told of the possibility of a fail- 
ure to effect a cure without exploring the pelvis and advised 
that it should be done in case of such failure. 

Some persons entertain the idea that examination by a 
female physician is less objectionable. Many of the women 
physicians show a disposition to encourage this view, and 
single women are frequently subjected to examination and 
the use of specula without sufficient cause. The sex of the 
examiner can make no difference in these cases. An exam- 
ination is an examination, by whomever made, and if it is 
undesirable it is none the less so because done by a woman. 

Examinations through a Speculum. — It frequently be- 
comes necessary to supplement the information gained by a 
digital examination by ocular inspection of the condition of 
the vaginal and cervix. The instrument most frequently 
used for this purpose is the bivalve speculum, a description 
of which can be found elsewhere. 

The Use of Bivalve Specula. — To use a bivalve speculum the 
patient must be in the dorsal position, as already described, 
the sheet being wrapped about her limbs as shown in Fig- 
ure 1. The blades of the instrument are well lubricated 
and taken in the right hand, being so grasped as to keep 
their points firmly in contact. The common point of the 
blades is then applied to the intervulvar crease with its 
greatest width corresponding in direction with the line of 
the crease. The labia majora can be slightly pressed apart 



38 MODERN GYNECOLOGY. 

with the tips of the blades as they are inserted. Care 
should be taken to keep the speculum in contact with the 
posterior vaginal wall and thus avoid striking the vestibule. 
When the blades have been introduced into the vagina a 
short distance, a rotation carrying the posterior blade to- 
ward the perineum should be begun, and so continued as 
the instrument is introduced that the greatest width of the 
blades should be from side to side of the vagina when the 
instrument reaches the cervix. This simple maneuver keeps 
the greatest width of the blades in line with the greatest 
width of the canal as it is passing into it, the vagina being 
widest in the vertical line at its outlet and in the transverse 
direction at the cervix. 

As the blades of the speculum approach the cervix their 
points should be made to separate by pressure of the thumb 
upon the lever. This separation should be so gauged and 
the direction of the speculum so guided that the cervix is 
between the points of the blades of the speculum as they 
move upward. If this is not done one of the blades must 
push the cervix aside as it is opened, and if -the mucous 
membrane is thin or there is erosion present, considerable 
injury may result. It is always more or less painful to the 
woman to have a blade of the speculum dragged across her 
cervix, and if she has previously been treated by a physician 
who has not done so, she will suspect the one who does of 
being awkward or inexperienced. 

If the cervix is large, and especially if ulcerated, one of 
the blades may catch in the external os and much difficulty be 
experienced in getting the entire cervix between the blades. 
If the laceration is deep it may be torn deeper in this way. 



EXAMINATIONS. 



39 



Where much enlargement of the cervix exists the blades 
should be so expanded as they enter as to be in close con- 
tact with the vaginal walls as they pass upward. This is 
especially important in cases of epithelioma, as it is desir- 
able to keep the mucous membrane over the cervix entire 
as long as possible. 

After the speculum is fully in place the blades must be 
separated wide enough to hold it in place and held there by 




Fig. 12. Bivalve Speculum in Position. 

the screw that follows the external lever. In Figure 12 
the bivalve speculum is shown in position, with the blades 
separated. 

Sims' Speculum (Fig. 13) has two blades attached at right 
angles to the ends of a shank. The blades are of different 
sizes, the smaller or virginal blade being slightly wider than 
the index finger. The wide blade is used for examining 
women with large vaginas and also for operations. This 



40 



MODERN GYNECOLOGY. 




Fig. 13. Sims' Speculum. 



instrument is so held as to draw the perineum backward 
and expose the cervix to view. With the patient in Sims' or 
the genu-pectoral position, it admits the air by opening the 

vulva and thus 
permits the pel- 
vic organs to be 
depressed toward 
the diaphragm. 
The manner of 
introducing Sims' 
speculum is shown 
in Figure 14. 

A depressor for the anterior vagina is needed with the Sims 
speculum to enable the operator to get a good view of the 
cervix and the upper parts of the vagina. Figures 15 and 
16 are probably the 
best forms of de- 
pressor in use. Each 
has its advantages, 
though Sims' fenes- 
trated instrument 
(Fig. 15) is the more 
satisfactory for ordi- 
nary use. 

Sims' speculum 
was the instrument 
devised for the pur- 
pose of seeing the cer- 
vix with the patient 
in Sims' position. It **■* Manner £gSn lms ' Specu?U!B *° r 




EXAMINATIONS. 41 

requires an assistant to hold it in position in cases re- 
quiring special manipulation. With some inconvenience 
the physician may gain a good view of the cervix and hold 
the speculum himself, but it is very awkward. At the same 
time it is almost impossible to make applications to the cer- 
vix, to pass a sound, or make intra-uterine applications. 

Any operation is simply out of the question without a 
nurse or assistant to hold the speculum. The manner of 




Fig. 15. Sims' Depressor. 

holding a Sims speculum is also of considerable importance 
to the operator. The accompanying cuts will show the dif- 
ferent ideas on this subject. The first (Fig. 17) is the method 
of holding the speculum recommended by Sims, the second 
(Fig. 18) is a modification of that method advised by Munde. 
The main requirements are that the tip of the blade be kept 




Fig. 16. Hunter's Depressor. 

far back in the hollow of the sacrum behind the cervix ; that 
force enough be made toward the tip of the coccyx to de- 
press the perineal body thoroughly, and that the instrument 
be held firmly and steadily without change of position. The 
way in which the assistant grasps the speculum is not of so 
much importance as the result he obtains in fulfilling these 
requirements ; but it is probably easier for him to do this in 
the manner recommended by Professor Munde than in any 



42 



MODERN GYNECOLOGY. 



other yet suggested. The relative position of patient, phy- 
sician, and nurse is shown in the illustration (Fig. 19). 

The objections to Sims' speculum have already been hinted 
at in describing the manner of using it. They are chiefly 

the need of an assistant to hold 
it in place and the difficulty of 
doing so. The latter objection 
is especially forcible in tedious 
operations. Any one who has 
tried it does not need to be 
told how trying an ordeal it 
is to hold a Sims speculum 
for even ten or fifteen min- 
utes, and when longer time is 
needed the difficulty is corre- 
spondingly greater. In making simple applications to the 
cervix or endometrium, or in examinations for diagnostic 
purposes, an assistant is frequently not conveniently at hand. 




Fig. 17. Sims' Method of Holding 
Sims' Speculum. 




Fig. 18. Method of Holding Sims' Speculum (Munde). 

Self = retaining Specula. — A number of self -retaining 
specula have been devised, that invented by Dr. Clement 
Cleveland of New York being most satisfactory. It is 



EXAMINATIONS. 



43 



described by the inventor in the following words : u It con- 
sists of two Sims blades, each with a flange, and separated 




Fig. 19. Relative Positions of Patient, Physician, and Nurse when using Sims' 
Position. (Sims:)" 



44 MODERN GYNECOLOGY. 

by an interval of one inch and three fourths (Fig. 20). 
These, though in parallel planes looking at them from the 




Fig. 20. Cleveland's Speculum. 

side 7 will be seen to be at a slight angle to each other when 
held with the concavity of either toward the observer (see 
Fig. 21), the nearer blade deflected to the right and the far- 




Fig. 21. Cleveland's Speculum. 

ther one to the left. At the point of each blade is a fenes- 
tra, and at the bend of the instrument, where the two blades 



EXAMINATIONS. 



45 



come together, is a narrow metal band. To complete the 
instrument, there is a belt of webbed material, to be applied 
about the waist. [This is best worn over one shoulder, to 
keep it from slipping downward when drawn upon. — C. H. 
B.] On this is looped, to admit of its being moved readily 
to any position upon the belt, a piece of the same material. 
To this is attached a long leather strap with oblong perfo- 




Belt to Cleveland's Speculum. 



rations placed at intervals of half an inch. At the point 
where this strap and the piece of belting are joined there is 
a hook (Fig. 22). 

" To apply the instrument, the belt is first buckled by the 
patient, not tightly, about the waist, and outside her cloth- 
ing, with the attached strap behind and the hook turned 
outward. She is then placed in the Sims, position. The 
operator selects the blade he thinks best suited to the case, 
and holding the instrument with the right hand, with the 



46 MODERN GYNECOLOGY. 

left he passes the leather strap through the fenestra at the 
point of the other blade and then under the metal band, 
leaving the strap quite loose between them. Then, holding 
the speculum still with the right hand, with the index finger 
extended along the concavity of the blade, it is introduced, 
care being taken to pass it back of the cervix. The instru- 
ment is then pushed firmly up against the perineum, the 
outer blade reaching a point just at the bend of the coccyx. 
In very thin women it may be necessary to place a folded 
towel under the external blade. The next step is to draw 
the leather strap tight, first through the fenestrum, and then 
under the metal band. The perineum is then retracted to 
the required degree by drawing the strap backward and 
securing it to the hook provided for the purpose. By now 
using the vaginal depressor, the cervix is brought at once 
into view." 

The flange holds up the buttock in the same manner as is 
done by the unemployed hand of the assistant in using Sims' 
speculum. The fact that the blades are at an angle to each 
other causes the blade within the vagina to move upward 
and backward in the same manner as is done by the assistant. 

This speculum is simple in its construction and inexpen- 
sive, but its main advantage is the absence of joints, hinges, 
or screws, making it easily kept aseptic. 

Figure 23 is a photograph showing Cleveland's speculum 
in position. I use this instrument in all operations about 
the cervix and in curetting the interior of the uterus. It is 
particularly convenient in repairing the lacerated cervix and 
in doing rapid divulsion for stenosis of the cervical canal. 
It can be used in making applications to the vagina, the cer- 



EXAMINATIONS. 



47 



vix, and intra-uterine, but the bivalve is more frequently 
used for these purposes. The self-retaining instrument is 
more applicable to bedside practice. The patient is not re- 
quired to turn across the bed, as she must to have a bivalve 
used. She lies on her side and need not hold up her knees 
to have the Cleveland instrument used. This is a very de- 




. mm 



Fig. 23. Cleveland's Speculum in Position. (From photograph, expressly 
for this work.) 



arable result when the patient is weak, as she frequently is 
when ill enough to be in bed. The patient in bed is less 
exposed when treated in the Sims position, because her legs 
and feet are not required to be moved around in changing 
her position in the bed. The self -retaining speculum can be 
used with the patient on either side, consequently it can be 
used at either side of the bed. 



CHAPTER II. 

MENSTRUATION. 

The menstrual flow in healthy females begins at puberty 
and ends with the menopause. There is no interruption in 
its regular recurrence, except during pregnancy and lacta- 
tion, that is not due to some pathological cause. 

Puberty is the term applied to the changes that occur 
when the individual passes from childhood to womanhood • 
she then becomes a perfect being and capable of reproducing 
her kind. Under normal conditions this is a quiet process, 
and she suffers no inconvenience from its advent if she is 
normal and healthy and has suitable environment. 

The Signs of Puberty are well known. The whole person 
expands, the bust enlarges, the breasts become round and 
full, the hips widen, the voice deepens, hair appears upon 
the pubes, and the menses appear. 

Changes have also been going on within the pelvis that 
are not evident externally except in their effects. These 
precede and cause the external changes. The uterus en- 
larges from an infantile to an adult uterus and rises higher 
in the pelvis, while the cervix dips more into the vagina, 
and the ovaries become active and begin their function by 
the swelling and rupture of a Graafian follicle. The Fallo- 
pian tubes are also involved and prepared to perform their 

48 



MENSTRUATION. 49 

part in the functional activity of the generative apparatus, 
which is to receive the ovum from the ruptured follicle and 
carry it to the uterine cavity, whence, unless impregnated, it 
is expelled. There is also a general congestion and enlarge- 
ment of pelvic vessels at this time. 

The menstrual flow seems to be associated with ovulation 
and is probably caused by that process, but there is doubt 
as to when ovulation occurs with relation to the flow. The 
theory most accepted is that the menstrual flow comes on 
during the period of enlargement of the Graafian follicle 
and before its rupture, this rupture occurring at any time 
from the first day of the flow to a week or longer after its 
cessation. Observations seem to indicate a considerable 
variation in the time of the discharge of the ovum in dif- 
ferent women. 

The Source of the menstrual blood is another point yet 
sub judice. There are observers who claim that it is dis- 
charged from the uterine vessels directly into the cavity of 
that organ. By another theory it is claimed that the 
uterus sheds its interior lining each month, to be renewed 
in the following weeks. The newer theories seem to be 
based on more scientific investigations, and claim that the 
discharge does not come from the uterus, but has its origin 
in the Fallopian tubes and travels thence into the uterine 
cavity. 

It is probable that there is a modicum of truth in all of 
these theories. The origin of the flow seems to be in the 
tubes or beyond them, and the amount may be small in the 
beginning, but it receives additions by exudation from the 
congested walls of the tubes and uterus during its transit 



50 MODERN GYNECOLOGY. 

through these canals and by exfoliation of epithelium from 
the mucous membrane covering them. These contributions 
received from the canal in transit are evidenced by the fact 
that detritus from both tubes and uterus is found in the 
material discharged when it is examined under the micro- 
scope. 

The interval between the " periods " of healthy women is 
about twenty-eight days, there being in this, as in all phys- 
iological processes, a normal variation due to individual 
causes and environment. 

The Duration of the flow also varies, with an average of 
about three days, which may, in individual cases, be reduced 
to two or increased to five. A flow of less than two or more 
than five days is usually from pathological cause, and should 
receive investigation as to its import and causation. The 
quantity of the discharge is also subject to a normal varia- 
tion. It is best estimated by the number of napkins worn 
per day, the usual number being from one to four or five. 
Some perfectly healthy women may soil several more than 
five in one of the days of the flow, but if this number is re- 
quired during more than one day, the flow is excessive and 
has a cause which needs investigation. The length of time 
the napkins are worn differs with the habits of the woman. 
One will wear a napkin until it is saturated with blood, 
while another will reject one which is only slightly stained ; 
hence these differences must be considered in estimating the 
amount of the flow by the number of napkins worn during 
a period. The quantity of blood expelled in clots must also 
be known in estimating the total loss at a period. 

The Age of the inauguration of the menses depends to 



MENSTRUATION. 51 

a considerable degree on the environment, particularly the 
climate and social conditions. There is a difference in races 
also which is probably an inherited result of the climate and 
social customs to which their ancestors became habituated. 

The age of puberty varies from the tenth to the sixteenth 
year, the former being common in tropical countries and the 
latter in colder climates. In temperate climates the age is 
between the twelfth and the fifteenth year. These limits are 
rarely deviated from, except in children of parents from a 
different climate. Cases are on record of menstruation in 
the second and fourth year, but such cases are abnormalities 
and of rare occurrence. The flow may also be absent to the 
twentieth year or longer, but there is usually lack of devel- 
opment or wasting disease when such is the case. 

When the woman is in perfect health and has normal sur- 
roundings in all respects she suffers no inconvenience from 
menstruating. The flow is perfectly painless from inception 
to cessation ; she does not know of its presence until the 
blood appears externally, and only knows it has ceased by 
ceasing to have the discharge. Like all purely physiological 
processes when performed under perfectly normal condi- 
tions, it is without sensation. When the number of civilized 
women who do have sensations of their menstruating is 
noted, the extent of their deviation from the normal is real- 
ized. A woman with perfectly physiological menstruation 
is rarely found. The average woman has pain at least for 
an hour or two, or she feels " dragged out " and " good-for- 
nothing " for at least one day in each month, or has some 
other abnormal sensations at this time causing her to feel 
not so well as at other times. 



52 MODERN GYNECOLOGY. 

These deviations from the normal are partially inherited 
in the form of misplaced or poorly developed organs and 
impaired general health, and are partially acquired from 
faulty environment, unhygienic clothing, and unwholesome 
habits of life. 

It is needless to more than mention the evil results due to 
the manner in which civilized women are dressed. The habit 
of supporting all the clothing for the lower portion of the 
body by fastening it around the waist is of itself sufficient 
to cause uterine deviations, pelvic congestion, and constipa- 
tion. But the unhygienic dressing of women is too well 
known to call for discussion here, mention of the fact being 
sufficient to show that it is an important factor in the pro- 
duction of menstrual abnormalities. 

The habits of many civilized women are also in utter dis- 
regard of consideration for themselves. Young girls will go 
out at night and dance for hours when they are menstruat- 
ing, subjecting themselves to dangers from overheating, too 
much laborious exercise, and loss of sleep. These things 
are particularly injurious at the time these functions are 
being called into play for the first time. The dancing is of 
itself a healthful amusement, but its excess and indulgence 
in it at improper times injures many young women. 

Menstrual Abnormalities. — It has been customary to de- 
vote considerable space to the consideration of the various 
abnormalities of the menstrual flow. This custom has been 
so general, in fact, that a book on gynecology would seem 
incomplete without it. In following this general custom it 
is necessary to emphasize the statement that these various 
deviations from the normal function are not in themselves 



MENSTRUATION. 53 

diseases, but are only symptoms of disease. In the early 
days of this branch of medicinal science amenorrhcea, dys- 
menorrhoea, leucorrhoea, and a number of other conditions 
were considered to be disease entities. But as knowledge 
has grown more exact and observation and investigation 
have assumed a more scientific basis, they have been rele- 
gated to the category of symptoms, many of them being due 
at various times to very different causes. 

Amenorrhoea, or absence of the menstrual flow, is a con- 
dition resulting from so many different causes that a chap- 
ter will be devoted to its consideration. Scanty menstrua- 
tion is a condition due in many cases to the same causes 
that eventually produce amenorrhcea, but from the impor- 
tance of the measures to be employed for its relief, a special 
chapter is more convenient for its proper description. The 
excessive loss of blood from the uterus will also be consid- 
ered alone. All of these variations from normal in the 
amount of the menstrual flow will be mentioned through 
the succeeding pages as symptoms of the other conditions 
therein treated of. The reason for devoting separate space 
to these symptoms is that their importance at times outranks 
that of the condition causing them in the danger or suffering 
they give the patient. Or to be more exact, the symptom is 
of itself the important thing to the patient, and it is for 
relief of this symptom that advice is sought. Oftentimes 
the causes are obscure or of neurotic origin. This of course 
is not a legitimate excuse for failing to find the cause ; but 
it may be necessaiy to relieve the symptoms before time can 
be given to sufficiently investigate the case to learn what 
produces them. 



54 MODERN GYNECOLOGY. 

Dysmenorrhea is a symptom so frequently the cause for 
which young women seek advice that a few words concern- 
ing it will not be amiss. The term is applied to pain occur- 
ring at or within a day or two either bef ore or after the 
menstrual flow. It has been classified in various ways, the 
best division being into "ovarian tubal" and " uterine"; 
the first variety being in the appendages and supposed to 
occur during the ripening of the Graafian follicles, the 
second being in the uterus during the expulsion of the 
menstrual blood. 

Varieties. — In the first class of cases the pain is usually dur- 
ing the first day of the period and not unf requently for a num- 
ber of hours before the flow begins. It is higher in the pelvis 
and more of a neuralgic character than the uterine pain, and 
is usually continuous. The pain of uterine dysmenorrhea 
is also at times a few hours before the commencement of 
the flow, but it is periodic in its intensity, resembling labor 
pains, and is usually followed by the expulsion of a blood 
clot with relief from the pain. The cessation of pain after 
the passage of the first clot of blood may be for the rest of 
that period, the remaining days being passed in comparative 
comfort, or it may be followed in a few hours by a new 
attack of "cramps" followed by the expulsion of another 
clot of blood, and so continue until the flow ceases. This 
form of pain has also been called obstructive dysmenor- 
rhea. It is due to two different causes. 

Causes. — The most frequent cause of uterine dysmenorrhea 
is stenosis of the cervical canal, the narrow orifice forming 
an obstruction to the passage of the blood from the cavity of 
the uterus. The blood accumulates until it, by its presence, 



MENSTRUATION. ~JO 

causes the uterine muscle to contract upon it with sufficient 
force to expel it. This contraction of the uterus is of the 
same character as labor pains j it also resembles them in 
being paroxysmal and expulsive. Dysmenorrhcea due to 
swelling of the mucous membrane lining the interior of the 
uterus is also obstructive in character. The internal os is 
practically closed by this thickened mucous membrane, and 
the contractions of the muscles forming the uterus are nec- 
essary to overcome the obstruction. 

Another cause of uterine dysmenorrhcea is the presence 
of an unyielding point in the uterine wall. When the organ 
becomes enlarged as a result of the congestion due to the 
increased amount of blood in its walls, pain is caused by the 
resistance the inelastic point offers to the swelling. This 
condition is usually found with congenital deviation, a con- 
dition often present with stenosis. Consequently this form of 
dysmenorrhcea is frequently found with the obstructive form. 

Dysmenorrhcea is often due to irritation of the nerve end- 
plates located in the walls of the uterus. Pressure due to 
the increased quantity of blood in the uterine vessels acts as a 
mechanical irritant to these nerve filaments, producing pains 
of a neuralgic character. The pains frequently present with 
scanty or delayed menstruation are of this character. 

An examination of the pelvis is not always to be had, and 
in some cases an effort to relieve the symptom may be justi- 
fiable before it is advised. But it must always be borne in 
mind that dysmenorrhcea is a symptom, and an effort should 
be made to learn its cause. When examined the cause will 
usually be apparent, placing the case at once in its proper 
category. If there is uterine congestion it will be discov- 



56 MODERN GYNECOLOGY. 

ered ; if stenosis or other cause of obstruction, that will be 
found ; if due to ovarian-tubal disease, the tenderness at the 
sides of the uterus and the enlarged appendages will demon- 
strate the fact. None of these conditions need further men- 
tion here, as each will receive attention at the proper time. 
After all these are eliminated a number of obscure cases 
will remain which are recognized as not belonging to any of 
them. The examining finger may find absolutely nothing 
to account for the pain; but usually a certain amount of 
tenderness is present, and leucorrhoea is commonly found. 
In these cases nothing more is found except some general 
symptoms, such as cold extremities, sluggish circulation, and 
digestive disturbances. 

Treatment — In these cases tonics, especially nerve tonics, 
as nux vomica, are beneficial. The low-pressure douche of 
warm water to the spine is used at Strathpeffer Spa with 
good effect. To use this remedy the patient sits in a com- 
fortable position, and the temperature of the water is from 
100° to 105° F. as is most agreeable to the patient. 

Hot vaginal douches, especially when taken a few days 
before the expected menses, will often relieve the pain and 
cause a painless period to result. 

Electricity cures a number of these cases of dysmenor- 
rhea. The faradic current is used, one pole being applied 
over the lumbar region behind, and the other pole across 
the lower abdomen just above the pubes. The remedy 
should be applied with the patient either sitting or reclin- 
ing in a comfortable position. The strength of the current 
should be governed by the feelings of the patient, and 
should be a little less than is painful. 



MENSTRUATION. 57 

The dysmenorrhea of non-parous married women is fre- 
quently relieved by galvanism. The negative pole is ap- 
plied intra-cervical or intra-uterine. When the cervix will 
not freely admit the electrode it can often be introduced by 
turning on the current and allowing it to pass by applying 
a little force as it enters the cervix. The current must be 
mild, not strong enough to produce pain. 

The treatment of dysmenorrhoea of ovarian-tubal type is 
not so satisfactory. If due to ovarian congestion or ovari- 
tis the treatment for those conditions is indicated. When 
due to salpingitis the treatment of those organs is to be fol- 
lowed. Electricity, either galvanic or faradic, may be tried, 
and vaginal douches (not above 110° F. if the ovaries are 
diseased) will add to the patient's comfort. Opiates or alco- 
hol in any form should never be used. 

Uterine Neuroses. — The subject of menstruation cannot 
be dismissed without some mention of uterine neuroses, and 
especially of their effects on the condition of the skin. Men- 
tion of the effects of reflexes from the uterus to the head 
and alimentary canal has already been made. The produc- 
tion of neuralgia, asthma, cough, hysteria, and loss of mus- 
cular control from uterine cause has also been considered. 
The uterine reflexes cause marked variations from the 
normal in the skin. The form taken is usually that of 
some eruption on the skin surface. Mistakes in diagnosis 
are common, the. true cause of the skin lesion being over- 
looked. 

Probably the most common form of reflex pelvic eruption 
is chloasma, and it is also the form most frequently attrib- 
uted to other causes. These uterine chloasmata are usu- 



58 MODERN GYNECOLOGY. 

ally supposed to result from liver disturbances. The feature 
about these " liver spots " is the fact that they change in size 
and distinctness as the uterine disease gets better or worse, 
showing their uterine causation. 

Many of these reflex eruptions are only seen at or just 
before the commencement of the menstrual flow. I have 
seen them take the form of burns, appearing on various 
parts of the body and gradually fading away. One case 
had these lesions from Ave past menstruations in various 
stages, from the fresh spots exactly like a deep burn that 
had been made with a low degree of heat to marks that 
could be seen as a very faint discoloration of the skin. 

Another case had an eruption resembling herpes covering 
the entire body from the feet to the head. The eruption came 
a day or two before the period and faded away within twenty- 
four hours after the flow began. Her pelvis was examined 
and found normal, and she complained of no discomfort. 
She was a widow and had had children. 

Another case had a typical scarlatina eruption covering 
the whole body, and only lasting a few days at the begin- 
ning of each menses. 

Frequently skin neuroses develop after castration. They 
usually occur about the time the period should have come, 
and remaining for a few days, fade away. They take any 
of the forms described, or may resemble bruises and take 
several months to disappear. 

The treatment of the pelvic lesion will usually cure the 
skin involvement. When there is no appreciable disease in 
the pelvis bromide of sodium will frequently be of benefit. 
Tonics for the nervous system should be used ; nux vomica, 



MENSTRUATION. 59 

arsenic, and phosphorus are good. Iron and stomachics can 
also be used. 

The chief importance of these skin lesions of reflex origin 
is in knowing their causes and import. 

Vicarious Menstruation is not a common abnormality, 
but it is occasionally met with. There is a loss of blood at 
some other point, and none from the uterus. In a typical 
case this discharge of blood recurs at regular intervals 
about four weeks apart. The blood expelled frequently has 
the peculiar odor so characteristic of menstrual blood. The 
amount lost varies just as the amount of the menstrual flow 
may vary in individuals. 

The vicarious discharge usually occurs from some surface 
covered with mucous membrane, although cases are seen 
when it comes through the skin. The most frequent place 
is the mucous membrane of the nose. The girl will have 
a hemorrhage from the nose about once a month. These 
cases are most common in girls who have never menstru- 
ated. Instead of the normal flow from the uterus the nose 
bleeds. In other cases the mucous membrane of the stom- 
ach is the site of the vicarious bleeding. The blood may be 
digested and pass on into the bowel. The only symptoms 
will be a certain amount of nausea and loss of appetite, fol- 
lowed in a day or more by a copious stool of digested blood. 
The blood may cause vomiting and the patient and her 
friends be greatly frightened at the " hemorrhage." Cases of 
this kind have been treated as ulcer of the stomach. The regu- 
lar periodic recurrence will aid in establishing the diagnosis. 

The flow may be from the mucous membrane of the ali- 
mentary canal below the stomach. When this occurs the 



60 MODERN GYNECOLOGY. 

blood will be expelled per rectum in a more or less digested 
condition, depending on the distance of its origin from the 
anus. If it come from the colon or rectum the blood will 
appear externally as a hemorrhage. A discharge of blood 
from the rectum has been mistaken for a normal menstrua- 
tion by inexperienced patients. Ulcers of the bowels or 
cancer in the rectum may cause a discharge of blood per 
anum, but the bleeding from either of these conditions is 
irregular in the time of its occurrence. The vicarious dis- 
charge is generally regular in its recurrence. 

Bleeding from the skin is not so common as from some 
mucous surface. I have seen two cases. In one the flow 
was from a small opening over the left pectoralis major 
muscle. The point of exit was about three inches above 
the left nipple. A small silver probe could be passed in two 
inches. There was no other abnormality about the chest. 
The development of the mammary glands was the same on 
either side. The amount of blood discharged each month 
was small. 

The other case of menstruation from the skin was from 
the surface of an ulcer. This ulcer gave off a bloody dis- 
charge every month. It was of limited amount, and when 
the sore healed and ceased to discharge the normal men- 
strual flow returned. 

The importance of these abnormal discharges is that they 
may be recognized and not be mistaken for some other con- 
dition. They are usually a symptom of some disease or 
malformation of the genital organs, and an investigation of 
those organs should follow the discovery of vicarious men- 
struation. 



CHAPTER III. 

AMENORRHEA. 

Amenorrhea is the name given to the complete absence 
of menstrual flow. It may be that the ovarian function has 
never begun, in which case it is called primitive amenor- 
rhcea. When the menses have appeared and then cease the 
condition is spoken of as an acquired amenorrhcea. It will 
be most convenient to describe each one separately. 

Primitive Amenorrhcea is, at times, a result of late de- 
velopment. The girl is not strong and the menses do not 
appear. She may go on until she is seventeen, eighteen, or 
even twenty years old before she matures. In these cases 
some impaired condition of the health is the usual cause. 
The diseases causing amenorrhcea are the so-called wast- 
ing diseases : — consumption or general tuberculosis, richitis, 
epilepsy, chlorosis, and the various other forms of anaemia. 
When the condition is due to any of the above causes the 
ovaries are usually normal and consequently capable of per- 
forming their function. The girl does not mature because 
of the impaired condition of her general health, not because 
of any fault in her genital system. 

Causes of primitive amenorrhcea may exist in the genital 

canal. These may be of two kinds. First, it may be due 

to absence of development of the ovaries, making it impos- 

61 



62 MODERN GYNECOLOGY. 

sible to have their function performed. The ovaries may be 
infantile, when they are very small, or they may be rudi- 
mentary, existing only as a small mass devoid of true ovarian 
tissue. In some cases the organs may be entirely wanting. 

Amenorrhea because of Impaired Development. — "When 
there is rudimentary or absent ovaries treatment is of no 
avail. The condition is not very common. In these cases 
frequently no symptoms are present beyond the amenor- 
rhcea. The girl grows up as other girls do and may seem 
in perfect health, but the menstrual flow fails to appear. 
She may have normal external genital organs with a vagina, 
uterus, and Fallopian tubes, or any or all of these organs 
may be wanting. If the vagina is present and patulous she 
may marry and have the marriage consummated, but of 
course cannot bear children. The sterility often is the 
cause of her seeking the advice which leads to a discovery 
of her condition. If the advice is sought before marriage 
she or some member of her family should be informed of 
the want of functional completeness and its consequences. 

Amenorrhea from Atresia. — The ovaries may be normal 
and their development may go on to maturity, but the 
menstrual flow fail to appear. This is due to a mechanical 
interference with the exit of the discharge. The case is 
then one of retained menstruation. The symptoms and 
treatment will be considered in chapters on atresia of the 
vagina and cervix. The usual point of closure of the canal 
is at the outlet of the vagina, the barrier being an imperforate 
hymen. 

The cases in which the ovaries are present and capable 
of performing their function are of more importance. At 



AMEXORRHCEA. 63 

times, in these cases also symptoms are entirely wanting, 
with the single exception of the absent development. The 
patient may suffer no inconvenience whatever, and only the 
fears of her friends may cause her to consult a physician. 
It is a popular idea that the absence of the menses causes 
consumption, this fallacy evidently coming from the fact 
that the flow is usually absent during the last months of 
this disease. 

The Symptoms of primitive amenorrhoea are generally 
those of the disease causing the impaired nutrition. The 
tuberculosis will be evidenced by the pale skin with the 
afternoon flushing of the cheeks, the scanty amount of flesh, 
the night-sweats and general weakness, and, if the disease 
be in the lungs, cough, expectoration, and the physical signs 
of phthisis pulmonis will also be present. The cases with 
consumption, however, are more apt to be suspended men- 
struation, as puberty usually has arrived before the disease 
has made sufficient progress to interfere with the develop- 
ment. These cases require the treatment for the tubercular 
condition, the amenorrhoea being a result needing no special 
consideration of itself. The question of diagnosis is the 
only one of importance here. 

Ancemia is a more frequent cause of amenorrhoea, and 
especially of primitive amenorrhoea or late menstruation. 
The other symptoms of anaemia make a characteristic pict- 
ure. There is want of color in the skin, lips, and sclerot- 
ics, the chalky whiteness of the latter being the most con- 
stant. The patient may be poorly nourished, but more 
frequently she inclines to stoutness with dyspnoea on exer- 
tion and weakness, and there is often an anaemic bruit 



64 MODERN GYNECOLOGY. 

found over the base of the heart and in the carotid 
arteries. 

These cases of anaemia are usually constipated, the condi- 
tion of the bowel being in many cases the cause of the blood 
impairment. The ill effects to the blood due to the reab- 
sorption of excrementitious elements from masses of fecal 
matter allowed to remain in the colon and rectum are evi- 
dent to every one who has heard of " fecal anaemia," and 
the amenorrhcea is a more remote sequence in the same 
chain of vicious results from a simple neglect. 

Menstruation is at times delayed in girls who seem per- 
fectly well, until they are seventeen or eighteen years of age, 
no cause being apparent. They are not anaemic nor afflicted 
with any wasting disease, and are frequently robust, with 
abundant color and excellent appetite and digestion. The 
only symptom aside from the absence of the menstrual flow 
is a tendency to eat pickles and other indigestible kinds of 
food, and an inclination to do unconventional things ; these 
are the outcome of a certain amount of irritation caused by 
the nervous reflexes. 

The question of examination in cases of primitive amenor- 
rhcea depends on the symptoms. 

Examination. — Evidences of moJimina menstruate must be 
inquired for, and if she has pains in the back and loins and 
heaviness in the pelvis which is worse on standing, and es- 
pecially if she has dysuria recurring each month with the 
above symptoms, an examination for imperforate hymen is 
essential. A simple inspection of the external genitalia 
made by separating the labia majora will decide this ques- 
tion. If the hymen is perforated and suppressed menstrua- 



AMENORRHEA. 65 

tion is still suspected, a straight sound can be inserted 
through the opening into the vagina, and passed upward to 
ascertain if atresia exists there. As examination with the 
finger will cause considerable pain if attempted through the 
opening in the hymen, rectal examination can be made and 
the size and condition of the uterus investigated; if it is 
enlarged and filled with retained menstrual blood, it can 
easily be made out, and the proper measures for its relief 
will naturally follow. 

Usually the inspection of the hymen and the probe in the 
vagina will be sufficient to reveal the condition of these 
parts ; at the same time the infantile external organs will be 
noted, the narrow thin labia, the short perineum, the short 
vagina, and narrowness of the vulvar slit are all apparent. 
Examination of the chest will allow the undeveloped condi- 
tion of the breasts to be discovered. These patients are usu- 
ally small, thin of flesh, shy, anaemic, with poor appetite and 
intervals of abnormal desire for food. 

When there is no evidence of the menstrual molimen in 
amenorrhcea due to anaemia, the physical development is 
frequently complete, but, because of the impaired condition 
of the blood, the flow does not appear. This is also the 
case with the robust non-anaemic cases, the failure of the 
organism to start the period being due to some impaired 
element in the nervous system. 

In cases belonging to any of the above classes inspection 
of the hymen and vagina with auscultation and percussion 
of the heart and lungs is all the examination indicated, the 
diagnosis being made almost entirely from the general 
symptoms. 



66 MODERN GYNECOLOGY. 

Treatment. — The treatment of anaemia will be given later 
during the consideration of acquired amenorrhcea. Consid- 
eration of those cases of primitive amenorrhea due to want 
of development and those due to impaired nerve force re- 
mains, the one being puny, poorly nourished, and timid, the 
other larger, better nourished, but erratic. 

For the first of these the hygienic treatment is of impor- 
tance. She must not study or read too much, as she is fre- 
quently inclined to do : nor must she be allowed to use up 
all her energy in physical work or her play. She is apt to 
be too intense in everything, taking the world too much in 
earnest, and feeling her disappointments with greater ear- 
nestness than the average child. Above all things she must 
not be told the object of her treatment, as it will only give 
her an additional cause for morbid worry. 

She needs plenty of mild exercise in the open air, cheerful 
surroundings, and the companionship but not the care of 
young children. She must be kept from society, late hours, 
and excitement. Light warm clothing is important, and 
daily baths followed by brisk rubbing until the skin glows 
will help her. Massage and sea bathing are frequently of 
benefit. The dietary must be plain but good, with no sweet- 
meats or pastry, but a plentiful supply of nourishing, easily 
assimilated food. The condition of the alimentary canal 
must be watched, and the appetite encouraged by-bitter ton- 
ics with laxatives when indicated. Gentian, strychnia, aud 
quinine with aloes are excellent remedies for these patients. 

Douches over the spine or shower-baths can be fried, and 
if well borne continued. Electricity may be given, in tonic 
doses, through the general system, the faradic current being 



AMENORRHCEA. 67 

used for this purpose ; its actiou directly to the pelvic or- 
gans is not so frequently indicated. 

Drugs to act directly on the amenorrhcea must not be 
neglected, though they rank second in importance in the 
treatment. The most efficient of all is probably iron, which 
can be given in the form of the tincture of the chloride with 
glycerine and strychnine, when the action of these bitters 
directly on the stomach is of benefit. It must be well 
diluted in water before taking, and the teeth must be 
guarded from its action. Better results will probably be 
obtained from the use of Bland's pill in large doses, as will 
be described under anaemia, the other drugs being given in a 
separate mixture. The permanganate of potassium and 
the binoxide of manganese are both good tonics, and a 
specific action in causing the menstrual flow is claimed for 
both. Amenorrhcea is frequently cured by them. 

Belladonna with strychnine and aloes has cured amenor- 
rhcea in the more robust cases where the cause is evidently 
in the nervous system. Bromide of sodium is beneficial in 
these cases. If pain is a symptom, acetanelid will act as a 
sedative and by its action on the circulation will relieve the 
congestion as well ; a small dose of the sulphate of quinine is 
an aid to the action of this drug. My favorite formula is : 

Acetanelid 3 j 

Quin. sulphat gr. x 

M. Ft. in capsula No. x. Sig. One capsule every two hours 
when needed. 

These capsules are especially efficient when much pain is 
present. 



68 MODERN GYNECOLOGY. 

When the hygienic and medicinal treatment fails to re- 
lieve the amenorrhea, local treatment may be required, espe- 
cially if marriage is contemplated in the near future. Elec- 
tricity can be used for this purpose. The faradic current is 
passed through the ovarian region by placing an electrode 
on the back and the other first in one inguinal region for 
five or ten minutes and then in the other for a like period. 
If a more immediate action on the ovaries is desired, one 
electrode can be applied within the vagina, either at the 
cervix or in the lateral fornix nearest the ovary being 
treated, while the external electrode is applied over the cor- 
responding ovarian region on the lower abdomen. If it is 
desired to get the effects even nearer to the ovary, the in- 
ternal electrode can be introduced within the uterus. These 
applications can be made every second or third day and 
their use continued for a number of weeks. 

If the f aradism fails the method recommended by Apostoli 
can be used. He uses the galvanic current, and taking ad- 
vantage of its chemical action in producing hemorrhage, 
places the negative pole within the uterus, the positive pole 
being applied over the ovary by means of a sponge or clay 
electrode. The flow once started in this way is apt to recur 
at regular intervals and a cure result. 

Another method of applying electricity is by means of an 
intra-uterine stem composed of zinc and copper arranged 
either in parallel layers or as a series of beads in which the 
metals alternate. A battery is formed as a result of the 
chemical action of the secretions upon the zinc. The amount 
of electricity generated in this way must be small, and it is 
doubtful if it has much effect upon the amenorrhea, the 



AMENORRHEA. 69 

benefit obtained from wearing these electric stems being 
largely cine to the presence of a foreign body in the litems. 

This stimulation to the functional activity of the nterus 
can also be obtained by the frequent passage of a large 
sound into the uterus. Where there is much congestion of 
the uterus and the flow does not begin simply because the 
habit has not been formed, the frequent introduction of as 
large a sound as can be passed without pain is stimulation 
enough to start the flow in a few weeks. 

If the congestion is very great and fails to be relieved by 
the sound or electricity, a leech may be applied to the cervix 
and allowed to remove enough blood to soil a half-dozen 
napkins, or the cervix may be punctured with a lancet and 
allowed to relieve the congestion by bleeding. These meth- 
ods are more frequently indicated for scanty menstruation 
and are fully described in the chapter on that subject. 

Acquired Amenorrhea differs from the primitive form 
in the respect that the menstrual flow has begun and existed 
for one or more periods before the amenorrhcea began. 

Causes. — The most common causes have already been 
mentioned, being consumption in its later stages, anaemia 
and chlorosis, and the wasting diseases in general. Occa- 
sional causes are colds, fright, and violent exercise at or just 
prior to the time for the period. The physiological cause of 
amenorrhcea, pregnancy, must also be thought of and mistakes 
guarded against It is also claimed that diabetes will pro- 
duce amenorrhcea, with atrophy of the uterus and ovaries. 
Change of climate is another frequent cause, girls coming 
from Europe being frequently without their menses for a 
number of months after their arrival. It is not known if 



70 MODERN GYNECOLOGY. 

tlie amenorrhoea is a result of the ocean voyage, the change 
in the manner of living, or the difference of climate, but the 
menses will return in the majority of cases without inter- 
ference. It is well, however, to give them treatment for the 
alimentary canal, if needed, with iron if anaemia is present. 

Amenorrhoea may occur in very young girls who men- 
struate one or more times and then the flow ceases. This 
condition rarely calls for any treatment except attention 
to hygienic surroundings and possibly tonics, such as nux 
vomica, iron, or quinine. The flow will usually return in a 
few months without the patient having suffered any disad- 
vantage from its absence. 

Amenorrhoea from Wasting Diseases, as consumption, dia- 
betes, chlorosis, or cancer, is almost always acquired, and is 
due to the conservative action of the organism in suspend- 
ing the loss of blood when it is already too much depleted 
to spare it. The amenorrhoea is only a symptom of the dis- 
ease, and its treatment requires no consideration aside from 
the regular treatment of the causing disease. 

When the flow stops suddenly during the course of a 
wasting disease, it is well to examine for possible pregnancy 
if the woman be married. This is more liable to be the case 
in patients who have phthisis, as they seem especially prone 
to conceive in the early stages of this disease. Women who 
have diabetes or chlorosis are more apt to be sterile. 

Amenorrhoea from Pregnancy will probably test the ingenu- 
ity of the physician more than any other class of cases he 
will meet. The patient usually comes to him reluctantly, 
and if she does come of her own volition it is with hope that 
her fears will not be verified. These circumstances will 



AMENORRHEA. 71 

make her information unreliable or misleading, and if bent 
on concealment she may be positively nntrnthfnl. Where 
pregnancy is suspected the physician must exercise every 
power of observation he may be possessed of. The girl who 
fears she is pregnant will act differently from the one who 
has nothing to fear from the most searching investigation. 
The questions can often be so put as to prevent her from 
suspecting their import. Discussion as to the condition of 
the appetite and digestion will naturally lead up to the in- 
quiry for nausea ; the time of day at which it occurs can 
usually be learned without special stress being put on the 
matter, and it can finally be learned if she has morning 
nausea or vomiting. After learning all about the condition 
of the stomach, inquiries concerning the condition of the 
bowels will naturally follow. It can then be learned if there 
is frequent micturition since the amenorrhcea began, and 
also if there has been increased leucorrhcea during the same 
period of time. 

Examination for pregnancy must take into consideration 
the breasts and external genitalia as well as the condition 
of the uterus. It is probably best to begin with the pelvic 
organs. 

The Vulva will be first inspected, and the size and color 
of the labia and introitus carefully noted. If pregnancy is 
present the dark-blue or deep-red color of these parts 
and the interior of the vagina will usually be found. This 
change in color of the external genitalia is a valuable sign 
of pregnancy, as it is so frequently present. It usually 
appears very early, at the time when positive symptoms 
are difficult to find. It may be only a slight reddening of 



72 MODERN GYNECOLOGY. 

the parts at first, which gradually deepens in color until it 
reaches a blue veinous tinge about the fifth month. It is 
seen early in the second month and is almost diagnostic 
when present, the only other conditions producing it being 
neoplasms of the uterus, and these cause menorrhagia rather 
than amenorrhcea. The absence of discoloration of the labia 
is not evidence that pregnancy does not exist, but its pres- 
ence is almost positive evidence of its existence. Enlarge- 
ment of the labia is another result of pregnancy, which is 
somewhat later in appearing in a sufficient degree to be 
diagnostic. 

The Hymen. — The condition of the hymen will be apparent 
when the labia are separated ; the presence of this membrane 
intact is by no means positive evidence that pregnancy does 
not exist, as it is possible for spermatazoa left on the vulva 
to find their way into the vagina and uterus, causing con- 
ception. The hymen is also at times elastic enough to ad- 
mit the examining finger without tearing. I saw one hy- 
men so rigid that it could not be ruptured by any justifiable 
amount of force with the examining finger, and coitus had 
been attempted a number of times but never accomplished, 
yet the woman had a gonorrhoeal vaginitis. The presence 
of the hymen in this case was no evidence of chastity. 

The absence of a membrane more or less completely clos- 
ing the vagina is not positive evidence that coitus has been 
performed, and consequently is of little importance as an 
evidence of possible pregnancy. The membrane may be- 
come broken in a number of innocent ways, or it may have 
been of limited extent in the first place. In the latter case, 
however, a rudimentary hymen will be found surrounding 



AMENORRHEA. 73 

the entrance to the vagina. The carunculae myrtiformes 
were formerly thought to be remains of the hymen. Coe 
claims that such is not the case, but that these small bodies 
around the introitus are caused by the rolling up of small 
particles of the vaginal mucous membrane carried down by 
the fetal head in delivery. If this theory is correct their 
presence is positive evidence that the woman has borne 
children. My experience shows that they are usually pres- 
ent in women who have borne children, but I cannot recall 
a single nullipara, married or single, in whom I have seen 
them. They are not likely to be found in a young woman 
with amenorrhcea in whom pregnancy is suspected. 

The Uterus. — The examination of the uterus naturally fol- 
lows inspection of the external parts, and should be made in 
the manner already described. The finger will ascertain 
the condition of the vagina as it is introduced. The cervix 
is the first point of importance reached. Its size and con- 
sistency are both of importance, especially the latter. The 
cervix of the pregnant uterus begins to soften around the 
external os in a few weeks after conception takes place. In 
the earliest weeks this soft velvety feeling will be confined 
to a very small zone immediately around the external os, 
which gradually enlarges as the pregnancy advances, until 
the whole cervix feels soft and pliable to the touch, com- 
municating an impression to the examining finger in marked 
contrast to the hard resistant cervix found in non-pregnant 
women who have amenorrhcea. This is a symptom rarely 
present in any condition but pregnancy, and is one of the 
signs most depended on in making a diagnosis. 

The size of the cervix also gradually increases as preg- 



74 MODERN GYNECOLOGY. 

nancy advances, but this does not occur so early as to be of 
much importance in the class of cases under consideration. 
Its chief importance is that it should be remembered, the 
opposite condition of infantile os, long and very small, being 
a sign of the probable absence of the pregnant condition. 

Segals Sign of Pregnancy.^- As the finger passes up at the 
side of the cervix, learning the size, direction, and consist- 
ency of that part around the internal os and of the fundus, 
the most important symptom to be sought is what is called 
Hegar's sign of pregnancy. When pregnancy occurs, among 
its earliest effects is a marked softening of the lower seg- 
ment of the body of the uterus in a zone just above the in- 
ternal os. This softening is at times so complete that no 
impression of resistance is conveyed to the examining finger 
at all. A number of cases are recorded by Sonntag (who 
recently published an article on the results of examining for 
this sign in a vast number of pregnant women in the mater- 
nity hospital at Berlin) in whom pregnancy was mistaken 
for a tumor, and in one the abdomen was opened for its 
removal before the true condition was discovered. In this 
case the softening of the middle uterine segment was so 
complete that no connection could be made out between the 
fundus and the cervix ; the latter was enlarged, and its up- 
per part was supposed to be the fundus in extreme retro- 
flexion, the fundus giving the impression of a mass in the 
pelvis separate from the cervix. 

Such extreme softening is not frequent, but a considerable 
degree of it can be made out in almost all cases of preg- 
nancy. The exceptions are usually due to the presence of 
unyielding tissue from stenosis or anteflexion. The impor- 



AMENORRHEA. 7 

tance of Hegar's sign is the early period in the gestation at 
which it can be made out, it being fonnd usually at the end 
of the fifth or sixth week. The only other condition that 
gives this symptom is " mollites uteri/' and it can be dis- 
tinguished by having the patient change to the Sims or 
genu-pectoral position, when the position of the uterus will 
change. Then mollites is never associated with the dark- 
ened labia and vaginal mucous membrane, and rarely with 
disturbance of the stomach. 

The Size of the uterus will also be ascertained in exam- 
ining for the other symptoms mentioned, a considerable 
amount of enlargement being present at the second month. 
Increase in the size of the uterus is not diagnostic of preg- 
nancy, but, with other symptoms, it helps to complete the 
chain of evidence which leads the physician to decide as to 
the condition present. It is well to remember that other 
causes may produce uterine enlargement. 

The Breasts. — The condition of the breasts must be learned 
when pregnancy is suspected. After the pelvic examination 
has been made little difficulty will be experienced in securing 
an examination of them. The darker color of the areola 
around the nipple is significant, and more so when the papillae 
are enlarged. The size and erectility of the nipple are also 
increased. The ability to express fluid from the breast has 
much importance attached to it by some authorities, but this 
can be done with some non-pregnant women, and it is not 
diagnostic of the early stages of pregnancy. It may, how- 
ever, have an influence on the patient herself and induce 
her to confess her indiscretion when she sees the "milk" 
come from the nipple. 



76 MODERN GYNECOLOGY. 

The signs and symptoms of pregnancy should be well 
known to every practitioner, and the greatest care must be 
exercised to exclude all possibility of its existence before an 
attempt is made to pass a sound or probe into the uterus. 
Women who are pregnant go to a physician hoping that if 
they deceive him as to their condition he may do something 
to cause them to abort. 

It is well in most cases not to be too positive in giving a 
diagnosis of pregnancy, especially where the girl maintains 
her innocence j an expression of opinion may be made, but 
the possibility of an error should be remembered. 

Anaemia. — Probably the most important cause of ac- 
quired amenorrhcea is anaemia ; the menses may have been 
present only a few times or they may have been regular for 
a year or more. With these patients the onset is a gradual 
one, the beginning symptoms being slight ; they first suffer 
from digestive disturbances, and are almost always consti- 
pated. These symptoms are followed by shortness of breath 
on exertion, oppression over the heart, tired feelings, loss of 
appetite, and loss of color. This condition may exist for a 
number of months before the menses stop, and if she does 
not fear she has " heart disease " and seeks advice for that, 
the patient may not go to a physician until the amenorrhcea 
sets in. Then she will come for something to bring back her 
" courses," fearing their absence will cause consumption. 

When examined she will be found to have a marbly 
whiteness of skin, blanched lips, and chalk-like whiteness of 
the sclerotics. She is frequently stout, but may be poorly 
nourished. The tongue is large and moist and may be 
coated white. The lungs are normal and the heart action is 



AMENORRHEA. 77 

normal, but a murmur is frequently heard over the base of 
the heart, the sounds being transmitted upward along the 
carotids. Examination of the genital organs is rarely indi- 
cated, the diagnosis being apparent from the general symp- 
toms. 

Tlie Treatment of the anaemia consists in removing all its 
causes and replenishing the depleted blood. The constipa- 
tion must be relieved first of all, and probably the most diffi- 
cult task in the treatment will be for this part of the disease. 
Cathartics of various kinds will be tried and may give relief 
for a time, but the patient soon tires of them and neglects 
to take them regularly. It is absolutely necessary for these 
girls to have a thorough evacuation of the bowels at least 
once daily. Another difficulty encountered is their inclina- 
tion to conceal their true condition in this respect. Ask 
any number of women the condition of their bowels, and 
in a majority of the cases the answer will be, " Oh, they are 
all right ; " yet further questioning will prove that they 
defecate but two or three times a week, or even less fre- 
quently. Unless impressed with its importance by their 
physician, this tendency to conceal the constipation present 
will be greater after they have been taking cathartics for a 
time. Many drugs are recommended highly for this pur- 
pose, and its attainment is attempted by other means with- 
out drugs. In order to succeed with either it must be 
remembered that, it is a habit that is being combated, and 
that it is necessary to remove the bad habit and at the same 
time replace it with a good one. 

The constipation habit is not cured in a few weeks but 
months, and at times years of daily attention are required to 



78 MODERN GYNECOLOGY. 

thoroughly eradicate it. Drugs for constipation should be 
such as can be used for a long time without injury, and as 
a consequence mercurials are only allowable for relief of an 
immediate condition and not for continuous use. When a 
speedy evacuation is required with as little disturbance as 
possible, it can be had by giving calomel in doses of one 
tenth of a grain every two or three hours until it responds 
freely. This can be repeated daily for a week or two, but 
not longer, and should always be followed by some non- 
mercurial laxative. 

Cascara segrada is probably the most satisfactory of all 
cathartics, and its use does not, as a rule, call for increasing 
dose with time, as many others do. It can be used alone or 
in combination in the form of the fluid extract, or the cor- 
dial may be taken alone. The latter preparation is not un- 
palatable, and a teaspoonful at bedtime usually causes a 
movement from the bowels in the morning without griping 
or other discomfort. The fluid extract combined with the 
official mistura rhei et sodii and powdered ipecac is very 
efficient, the appetite frequently being increased by its use. 
If indicated, tincture of nux vomica can be added to the 
above. A satisfactory formula is as follows : 

Pulv. ipecac gr. vj 

Tine, nucis vomicae 3 iij 

Ext. cascar. fluidi 3 iij — 3 v 

Mist, rhei et sodii q. s. ad § vj 

M. Sig. 3 ij before each meal in a half -tumbler of water. 

Enemata high enough to flush the entire colon have 
recently been recommended for the cure of constipation, 



AMENORRHEA. 79 

two or three quarts of water being used for this purpose. 
When first attempted the muscles around the rectum pre- 
vent the entrance of the water into the colon, but a few 
trials enable any one to fill a greater portion of the colon. 
There can be no doubt of the benefit of a thorough wash- 
ing out of the colon, and the occasional use of these high 
enemata may help to cure the constipation, but its con- 
tinuous use is of doubtful propriety. In this respect, as 
in therapeutic measures generally, it is unwise to rely en- 
tirely on one remedy, an association of several being more 
efficient. 

Exercise has much to do with alimentation, and especially 
in securing a daily stool, consequently daily walks and drives 
are essential. The amount of time spent in the open air 
should be as long as possible without tiring. All forms of 
exercise should be light so as not to injure, and all violent 
movements eliminated from any gymnasium or other exer- 
cise taken. 

Massage and baths with frequent rubbing of the skin will 
be efficient aids to the treatment of these constipated cases, 
and should be given where possible. Massage of the abdo- 
men following the line of the colon is of benefit. It should 
be done every morning. 

The condition of the blood is a result of vicious condi- 
tions and next to their removal needs attention. The best 
drug for this purpose is iron, and it must be given fearlessly. 
The most satisfactory form of iron is Bland's pill, silver 
coated, and two or three five-grain pills should be given 
after each meal for several months. Forty or fifty grains of 
Bland's pill can be given daily with marked benefit. If head 



80 Modern gynecology. 

symptoms or hemorrhage from the nose result, the amount 
of iron must be diminished or some other drug given. 

Arsenic may be needed with or without the iron, the 
official liquor potassii arsenitis being an excellent form to 
use. The dose can be gradually increased as tolerance is 
established, and the drug can be used for a number of 
months without harm. 

Cod-liver oil, milk, cream, and easily assimilated foods are 
required where the body weight has depreciated, the con- 
dition of the alimentary canal being attended to by use of 
such drugs as are indicated. 

When the anaemia yields to the treatment the color returns 
and the general health improves. As a result of the restored 
normal condition of the system at large, the menses return 
and resume their monthly cycle. 

Amenorrhea with Plethora. — Amenorrhcea is occasion- 
ally found in women who incline to increasing stoutness ; as 
they grow larger the amount of the flow becomes smaller 
each month, until it finally disappears entirely. These 
women are generally sterile, and usually have considerable 
pain at the time of their periods ; they feel dull and listless, 
and have headaches and nervousness. Leucorrhcea is a 
common symptom, and sexual desire diminishes as the 
stoutness progresses. 

Examination fails to reveal anything significant in the 
pelvis of these women as a rule. Occasionally there is 
ovarian tenderness and a sensitive vagina. 

Treatment is usually not satisfactory. As these patients 
get stouter, the ovarian function is suppressed entirely, as a 
result of atrophy of those organs. The iodide of potassium, 



AMENORRHEA. 81 

with or without mercury, may be of benefit, as it will stop 
the accumulation of adipose tissue and may even reduce the 
weight. Cathartics may be needed, and if the patient is 
anaemic iron should be given; the syrup of the iodide of 
iron being an excellent form to give in the latter case. 

Suppression of the menstrual flow may occur without 
known cause. There is neither wasting disease nor anaemia. 
Its beginning may date from a cold, a flight, or sudden 
shock at the time the flow is due, or from over-exertion or 
a bath taken about that time. The patient suffers little dis- 
comfort from anything but the amenorrhoea. She may have 
some distress each month about the time the period is due, 
with a feeling of heaviness in the pelvis, backache, and full- 
ness about the top of the head. 

Examination of the pelvis will reveal nothing except a 
slight congestion of the cervix and vagina, and even that 
may be absent. 

Treatment is usually not required directly for the amenor- 
rhoea, as that symptom usually disappears in a short time. 
If other symptoms are present they must serve as an indi- 
cation for the proper plan of treatment. If the menses fail 
to return and no cause for their absence can be found, some 
of the various methods for starting them may be tried. 

Among the drugs used to cause a recurrence of the sup- 
pressed menstrual flow the binoxide of manganese is prob- 
ably the most popular. It is usually given in pill form, and 
the dose is from one to four grains three times a day. The 
action of this drug is usually prompt and the recovery is 
complete. The permanganate of potassium was formerly 
used, but has in a great measure given way to the man- 



82 MODERN GYNECOLOGY. 

ganese. Iron, arsenic, and quinine have each a place in the 
treatment of amenorrhcea, which is chiefly due to the cura- 
tive effect of these drugs for the conditions of which the 
amenorrhcea is a symptom. 

The use of ergot, tansy, sandalwood oil, the fluid extract 
of cotton-root bark, and drugs of this class, is always dan- 
gerous. They all act by producing pelvic congestion or in- 
ducing uterine contractions. It must also be remembered 
that a frequent cause of amenorrhcea is pregnancy. This 
may occur in any case, and abortion is liable to follow the 
use of powerful emenagogues. Quinine and the binoxide 
of manganese may also produce abortion if given in large 
doses. Consequently pregnancy must be carefully elimi- 
nated before pushing these drugs. 

In all forms of treatment for amenorrhcea the fact that it 
is a symptom must be kept in mind. The cause can fre- 
quently be found and will guide the treatment, and it is 
well not to be satisfied with any treatment until a cause for 
the symptom can, be found. As knowledge of the genera- 
tive organs becomes more exact the number of cases of 
amenorrhcea whose etiology is unknown will diminish. 

Amenorrlma from Hyper-involution. — Amenorrhcea occa- 
sionally results from hyper-involution following pregnancy. 
The symptoms are not many as a rule. The absence of the 
menses is supposed to result from lactation while that func- 
tion lasts ; but after the child is weaned the menses do not 
return, and a physician is consulted. The woman may think 
she is pregnant again, as many women, especially among the 
poor, are pregnant before they cease nursing. I knew of 
one woman who never menstruated in seventeen years, being 



AMENORRHEA. 83 

all the time either pregnant or nursing. An examination 
made a few months after delivery would discover the tend- 
ency to atrophy from the too long continuance of the invo- 
lution process. This examination should always be advised 
by the accoucheur. 

Examination of the pelvis will discover a small uterus 
with a short cervix. The ovaries can seldom be made 
out at all and are small. There may be paleness of the 
vaginal mucous membrane and cervix. The uterine canal 
is short. 

Treatment by electricity or frequent passage of the sound, 
with drugs for the general health, will usually restore the 
function in a few months. A subsequent pregnancy will 
enlarge the uterus, and a return to the normal size usually 
follows its termination. 

Amenorrhea Following Castration. — Amenorrhcea as a rule 
follows removal of the uterine appendages when both are 
taken out. The flow may return from habit for a few 
months or even a year, but the rule is for it to cease in a 
very short time. When the menses continue for a consider- 
able time it is frequently the result of a small amount of the 
ovarian tissue that has escaped the surgeon in the removal. 
Periodic uterine flow has resulted when only a small piece 
of the tube was left adherent to the uterine horn, and ceased 
after its removal by subsequent operation. 

Examination may demonstrate the presence of consider- 
able congestion of the uterus. The hemorrhage may result 
from contracting bands in the pelvic peritoneum, causing 
either direct or reflex irritation. When present, these bands 
of adhesion can usually be made out by vaginal touch. 



84 MODERN GYNECOLOGY. 

They frequently cause much pain, and may involve intes- 
tines, causing obstruction. 

The treatment consists of douches and vaginal applica- 
tions for the uterine congestion, as will be described in the 
chapter on uterine hemorrhage. Remedies for removal of 
the adhesions are also indicated. The latter object is at 
times accomplished by the use of Monsel's solution and firm 
packing of the vagina with tampons. In order to accom- 
plish much in this direction the applications must be made 
as often as can be borne and their use continued for a num- 
ber of months. 

If no progress is made in two or three months, electricity 
may be tried. The f aradic or galvanic current may be used, 
and can be sent through the adhesions by placing the inter- 
nal electrode either within the uterus, or first in one lateral 
fornix of the vagina and then in the other. The advocates 
of the use of this force to dissolve pelvic adhesions claim to 
get excellent results with it, and it should have a trial in all 
obstinate cases. A second laparotomy may be necessary to 
remove these adhesions. 

The object of treatment is to hasten the advent of the 
premature menopause which should result from the removal 
of the ovaries. The manner of its coming is similar to the 
normal process, and the symptoms are the same. In order 
to avoid repetition they will be described in the pages 
devoted to that condition which follows. 

The Menopause is the normal cessation of the ovarian 
function as a result of age. It marks the termination of 
the dual existence of a woman. From puberty to this time 
the woman lives as an individual and also as a factor in the 



AMENORRHEA. 85 

perpetuation of her species. The latter part of her condi- 
tion is the one made most prominent during its activity, 
and the one for whose accommodation her individual ex- 
istence is made subservient. 

Each ovulation is a setting free of an element from her 
capable of being developed into a new being. This libera- 
tion of ova is only suspended during gestation and lacta- 
tion, the energy of the mother being drawn upon to furnish 
material for the development of the growing offspring dur- 
ing this time. The only other suspension of the function of 
ovulation is when the integrity of the individual suffers to 
such an extent as to make it impossible to continue the 
process and live. Then the individual asserts itself and a 
conservative cessation results. 

When the ovaries begin to atrophy from age, their func- 
tion gradually becomes less active and eventually ceases 
entirely. These results of senility cause the climacteric, or 
" change of life." 

Ovulation may permanently cease when the woman is 
quite young, causing a premature menopause • but it is 
usually the result of senile atrophy of the ovaries. The age 
of a woman's generative organs is not always measured in 
years. In rare instances the menopause has been passed by a 
woman under the thirtieth year. The usual time is between 
the forty-second and the forty-seventh years. Occasionally 
the menses continue until after the fiftieth year, and rare 
cases are met in which the function is. active beyond the 
sixtieth year or even later. 

When the menstruation continues after the usual time an 
examination is advisable, as the flow mav continue as a re- 

: y ........ ■ 



86 MODERN GYNECOLOGY. 

suit of fibroma or carcinoma. This is especially important 
when the discharge has been absent for a time and returns. 
Women often look upon this event as an evidence of a re- 
turn of youth, and do not seek advice until the disease caus- 
ing it is beyond the reach of treatment. The importance of 
early appreciation of cancer and the fact that neoplasms in 
the uterus of old women are usually malignant, calls for 
examination at the earliest moment, when suspicious flow of 
blood is found. 

The menopause rarely is inaugurated suddenly. The pro- 
cess is usually a gradual one. When the woman is well and 
her surroundings normal the change is generally attended 
with little inconvenience. But few women are in perfect 
health at this period of life, consequently considerable suffer- 
ing results during the change in most cases. 

The beginning is usually marked by missing a period, or 
she may go three or more months without menstruation. 
Then there is one or more normal periods followed by a 
longer interval, and the change tarries along for a year or 
two. In other cases the time between the periods gradually 
lengthens to five weeks, then to six, and so on until it ceases. 
Women may miss one period and then be perfectly regular 
for six months or more before missing another. Again, the 
change may be in the amount of blood lost at each period. 
This will be less each time, until it is lost entirely. At 
times, after an absence of one or two months there will be 
one or more periods marked by an excessive loss of blood. 
Karely the change is abrupt, the last period being normal in 
all respecis and the function ceasing with it, never to return. 

The importance of a knowledge of the manner in which 



AMENORRHEA. 87 

the menopause comes and the symptoms usually found re- 
sulting from this change is that the physician may be able 
to distinguish it from other conditions. It is a physiolog- 
ical process, and should not be confused with any of the 
pathological changes that may occur. The earliest signs of 
the climacteric are of especial importance. 

There are some symptoms of beginning menopause that 
can usually be found before the changes in the menstrual 
discharges are noticeable. Naphey claims that the very first 
sign of this change is the beginning of the accumulation of 
fat. This, he claims, is first "visible in the lower part of 
the neck on a level with the lower two cervical vertebrae.' 7 
The fat in this position often grows to " form two distinct 
prominences," and " is an infallible indication " of the period 
in the woman's life. 

The usual tendency is to go on to increased stoutness as 
the change is completed. This is especially the case when 
the woman is in health. Many women are better after the 
menopause than at any time in their life. 

When the amenorrhcea of the climacteric appears there 
are usually a few days at the time the flow should come dur- 
ing which considerable inconvenience is experienced. At this 
time the woman will have feelings of fullness in the head, a 
flushed face, and general distress in the chest and abdomen. 
A frequent complaint with these patients is that the blood 
formerly lost has gone to the head. At the same time con- 
siderable distress is felt in the pelvis. A feeling of heavi- 
ness, which is aggravated by the upright position, is com- 
mon. Irritability of the bladder is frequent, and irritable 
bowels causing diarrhoea occasionally occurs; more fre- 



88 MODERN GYNECOLOGY. 

quently the latter symptom is supplanted by constipation, 
with much bloating of the abdomen from gas in the colon 
and intestines. It is not uncommon for these women to 
imagine they have a tumor, or, as they express it, " some- 
thing growing" in the abdomen. The moving of the gas 
in the bowels has been mistaken for fetal movements even 
by women who have had a number of children. This fact 
with the amenorrhcea present has caused many a patient to 
think herself pregnant when it was the beginning of her 
climacteric. This error must not be too readily acquiesced 
in by the physician. 

Neurotic symptoms are common in women at the time of 
the transition from active to inert sexual life. The disturb- 
ance in the circulation acts on the nervous reflexes and on 
the great nerve center, the brain. The symptoms caused by 
this irritation vary from simple attacks of " nerves " to de- 
mentia or active mania. There may be hysteria or paraple- 
gia. In fact, this period of life may be productive of any 
or all of the numerous ailments of a reflex character that 
characterize pelvic disease at any time. It is a time of anx- 
iety to the patient and her friends. 

This is the time when pelvic growths are apt to make their 
presence known. Fibromata, if they have not been discov- 
ered before, will increase the symptoms and cause the woman 
to suffer more. But the fact that tumors of this character 
usually grow smaller as the ovarian function ceases makes 
them of less importance. If the tumor has not caused in- 
convenience before the menopause begins, it can usually be 
managed without great interference, for, as the congestion 
incidental to the menstrual flow ceases, the blood-supply for 



AMENORRHEA. 89 

the fibroid is diminished. The result is atrophy of the tumor 
at the same time that the physiological atrophy goes on in 
the ovaries and uterus. The surgeon takes advantage of 
this natural method when he induces an early menopause by 
castration. 

On the other hand, tumors of a malignant character do 
not have a tendency to self -cure as a result of the dying ova- 
rian function. They seem rather to be aggravated by this 
change in their surroundings. The lessened blood-supply 
promotes the tendency to necrosis of tissue and the conse- 
quent sloughing is greater. The extension of the growth to 
other parts meets less resistance from the less active tissues 
and is consequently rapid. 

Examination of the pelvic organs should always be made 
about the fortieth year. The frequency of serious disease at 
this time makes this important. Many cases of cancer would 
be discovered in time for radical removal if this were more 
frequently done. 

The accumulation of fat will be discovered first on exam- 
ination, and uterine exploration of the pelvis will show the 
cervix large and congested. This will be greater if the ex- 
amination is made at the time the menses should occur. If 
a tumor exists in the pelvis the symptoms due to it will also 
be found. 

The Treatment is dependent on the complications. If none 
exists, the treatment is entirely palliative. At the time the 
menstrual flow should appear the pelvic congestion can be 
relieved by painting the vagina with iodine and creosote, 
followed by the application of tampons saturated with glyc- 
erine. This treatment can be repeated every second day 



90 MODERN GYNECOLOGY. 

until the distress is relieved. After the removal of the tam- 
pons copious hot-water douches should be used two or three 
times daily until the next treatment. This will diminish the 
pelvic congestion and relieve the head symptoms. When 
applying the tincture of iodine and creosote to the vagina it 
is advisable to make an intra-uterine application of the same 
solution to help remove any tendency to metritis that may 
exist. 

The neurotic symptoms that are frequently so annoying 
can be controlled by the bromide of sodium in full doses. 
If much flatus be present the rhubarb, soda, and ipecac 
mixture with nux vomica will be of service, or the following 
combination containing the bromide may be used : 

Sodii bromid § j 

Pulv. carbon 3 ij 

Ext. pancreatici 3 j 

Aqua, anis q. s. ad. § iij 

M. Sig. 3 j a half -hour after meals in water. 

The condition of the evacuations must be inquired into 
and cathartics or laxatives given as indicated. Where much 
debility exists iron and other tonics must be given, and if 
there is tendency to lose flesh cod-liver oil must be added. 

Much patience is required with women during this tran- 
sition period. They require encouragement in large quanti- 
ties. The support of a tampon in the vagina will at times 
allay much of the distress complained of, and it may be 
needed once every week or fortnight for a long period of 
time, even when no pelvic symptoms are present. 

The use of opiates must not be allowed, as great danger 



AMENORRHEA. 91 

of acquiring a habit exists. The powers of endurance are 
frequently taxed to the utmost and control of appetite 
materially impaired. Alcoholic and malt drinks must also 
be interdicted for the same reason. The use of whiskey and 
gin to hasten retarded menstrual flow is not in accordance 
with the therapeutic indications and should be discouraged. 
The only effect alcohol can have is to produce a slight numb- 
ing of the nerves of sensation. It does not promote an in- 
crease in the amount of the flow nor in any way modify it. 

Moderate open-air exercise is beneficial, and should be 
encouraged to prevent the tendency to melancholia so fre- 
quently present. The attendants of these old women must 
be cheerful and capable of encouraging them out of their 
" blues." They should be encouraged to employ their time 
in some light labor to prevent ennui and keep them from 
brooding over their ills and woes. 



CHAPTER IV. 

SCANTY MENSTRUATION. 

Scanty Menstruation, like amenorrhea, is a symptom 
and not a disease of itself. The diseases causing each are 
in many cases the same. At times the scanty menstruation 
is only the beginning stage of an acquired amenorrhea. 
The amount of the flow may be only slightly less than nor- 
mal. The fact that women vary greatly in the amount of 
blood lost must be taken into consideration in deciding 
whether or not the flow is too small. An amount of blood 
that would be copious for one woman might be slight for 
another. 

Causes. — Scanty menstruation, when found with anamiia 
or wasting disease, becomes simply a symptom of these con- 
ditions and merits no special consideration of itself. There 
are cases of scanty menstruation found in women who seem 
to suffer only from the pelvic condition causing it. For 
some reason the blood in the pelvic tissues does not make 
its exit in the usual amount and a condition of pelvic con- 
gestion exists as a result. The causes of this failure to 
have a free flow are obscure. They are at times neurotic, 
and again they may be the result of the condition of the 
blood. 

When the blood is thick from any cause it finds difficulty 

93 



SCANTY MENSTRUATION. 93 

in making- a passage through, the walls of the vessels. 
Patients who have this cause for their scanty menses are 
usually plethoric and of sluggish habits. Their circulation 
is poor, they move slowly, and their minds are inert. They 
are, at times, anaemic, and frequently have jaundice. They 
are capricious eaters, with poor digestion and constipation. 
The menses last only a day or two, the amount of flow being 
slight. Dysmenorrhea, leucorrhcea, and "nerves" are other 
symptoms frequently found. 

Another class of women witli scanty menstruation differs 
materially froin those described above. They are small, 
wiry, energetic women, peaked faced and poorly nourished, 
but full of restless energy. Anaemia is usually present in 
these patients, but they flush easily on exertion or when 
excited. A proclivity to enter into whatever they under- 
take with more force than they have strength to endure is 
a prominent characteristic of these women. They are given 
to " blues," and again they are exceedingly joyous, passing 
from one state to the other with the greatest rapidity. 

Chronic inflammation near the uterus is also given as a 
cause of scanty menstruation. 

Other symptoms present with the scanty menstruation are 
dysmenorrhcea, leucorrhcea, and constipation. The small 
amount of blood lost is in part due to the fact that they use 
up too much vitality in their work or pleasure to allow 
much to be lost in menstrual flow. Then the congestion of 
the pelvic vessels acts as an irritant, stirring up the whole 
nervous system through the reflexes. These patients may 
become hysterical or have other nervous complications. 

Cases of delayed menstruation are frequently found with 



94 MODERN GYNECOLOGY. 

the scanty menstruation. The menses do not come at the 
usual time, but a few days after time. The symptoms pre- 
cede the flow for several days, and are characteristic. The 
pain of a dull aching character is felt in the lower abdomen. 
There is bearing down, backache, and the general feeling as 
if the menses were about to appear. But they do not come 
on, or it may be after a number of hours that a slight show 
is seen, which only lasts a short time. When it stops the 
symptoms become more severe. The heaviness in the pelvis 
and the dragging-down feelings last for several days, when 
they are relieved by the inauguration of the flow in suffi- 
cient quantity, or are increased by its failure to come. If 
the period does not come the symptoms gradually fade away 
after a number of days, and may be entirely absent until 
just before the time for the next menstruation. 

Another cause of scanty menstruation is uterine displace- 
ment, especially retroflexion of a large heavy uterus. The 
latter condition, however, is more frequently accompanied 
by an excessive menstrual flow. The beginning of the period 
may be delayed a number of days even when a profuse men- 
struation results. 

Examination for Scanty Menstruation— The condition of 
the pelvic organs when examined will vary, their condition 
depending on the time at which the examination is made. 
If examined immediately before or after the menses much 
congestion will be present in the vagina and cervix. The 
uterus will be large, boggy, and tender on pressure. It fre- 
quently is displaced, but may be normal in position. The 
symptom of chief importance is the congestion. This is 
due to an engorgement of the tissues with blood which 



SCANTY MENSTRUATION. 9o 

should be removed by the menstrual flow but is not, because 
the flow is scanty. The presence of congestion is shown by 
a drop of blood that usually follows the probe when with- 
drawn. The ovaries may be swelled and tender, and at 
times are displaced into the cul-de-sac of Douglas. 

As seen through the speculum the vagina and cervix are 
thick and deep red from the presence of too much blood in 
their vessels. 

Treatment. — This engorgement gives the cue to the treat- 
ment. Anything to relieve the pelvic congestion will im- 
prove the condition of the patient, though it may not cure 
the scanty flow at once. A number of remedies are em- 
ployed for this purpose. Space given to each will be found 
most satisfactory in describing them. As some of the sim- 
pler methods will usually be tried first they will receive first 
mention. Several of them may be carried on at the same 
time. 

The treatment of the general health has been outlined in 
the chapter on amenorrhcea. Everything must be done to 
build up the system, to increase the assimilation of food, and 
to restore the tone to all the tissues of the body. 

The use of remedies directly to the pelvic organs is also 
needed. Two methods exist by which this congestion can 
be lessened : either the blood can be driven out of the pelvic 
organs, or it can be withdrawn by measures which remove 
it. I unite with Davenport in thinking that the applications 
to drive the blood from the pelvic organs are indicated dur- 
ing the inter-menstrual period, while the depletion is re- 
quired just before the time for the period. The first indica- 
tion is met by the use of copious hot- water douches (after 



96 MODERN GYNECOLOGY. 

the manner to be described) during the interval between 
the periods. Treatment of the vagina and cervix are 
also made every five days during this time. For depleting 
the tissues just before the menses appear, the douches 
must be discontinued and other measures substituted. It is 
also well to give a brisk cathartic at this time, thus deplet- 
ing the immediate neighborhood of the bowels. Two or 
more laxative pills containing aloes can be given at night 
for this purpose. If the menses are usually delayed, a treat- 
ment with electricity may hasten their coming. The nega- 
tive pole is applied within the uterus as directed for amenor- 
rhea. This may cause a more abundant flow at the same 
time that it causes it to come sooner. If sufficient flow fails 
to appear as a result of the electricity, some depleting meas- 
ure must be employed. Puncture of the cervix is a method 
frequently used. The application of a leech to the cervix 
resembles the natural method more and is consequently 
preferred by some. These methods both remove the blood 
entirely from the tissues. The use of glycerine tampons 
depletes in a different way. These tampons are saturated 
with boro-glycerine and new ones inserted every ten or 
twelve hours. The action of the glycerine causes the serum 
of the blood to enter the vagina and find its exit by follow- 
ing the cord to the vulva. These glycerine tampons are used 
for several days, until sufficient serum has been removed 
from the pelvic circulation to relieve the congestion. The 
treatment with hot- water douches is resumed a few days later. 
As has been stated in writing of amenorrhea, the various 
drugs supposed to act directly on the uterus are not reliable. 
They almost never do any good, and frequently do harm. 



SCANTY MENSTRUATION. 97 

The use of vaginal douches to driv3 the excess of blood 
from the pelvis calls for a more detailed description. In 
the first place the douches must be copious so as to insure 
a prolonged contact. An appliance must be had that will 
hold at least six gallons, and the tampons must be high 
enough to produce contraction of the muscular coats of the 
arteries. This latter condition is the result to be obtained 
by the hot- water douches, and when the stimulus is sufficient 
the vessels remain contracted for a number of hours. 

The details of giving a douche and the preparation for it 
are important. It is very often given improperly, producing 
results that are disappointing to the physician and discour- 
aging to the patient. 

The first consideration must be for the appliance for giv- 
ing the douche. The syringes formerly in use are not suit- 
able for this purpose. The Davidson pattern gives an 
irregular stream of water. The force exerted by the water 
striking the tissues is irregular and spasmodic. It may be 
sent in with enough force to set up inflammation. Tins ob- 
jection has been partially overcome by the use of an elastic 
bulb or pipe between the hand-bulb and the tip. This gives 
an almost continuous stream, and lessens the force of the 
first impulse. But the other objection to this variety of 
syringe is a greater one. When it is required to give a 
douche of five or six gallons of water much labor is required 
to pump so large a quantity. This is more laborious when, 
as is frequently the case, the patient attempts to administer 
the douche herself. It is very tiresome to pump so long, 
and the uncomfortable position in which it must be done 
makes it much more so. When a copious douche is at- 



98 MODERN GYNECOLOGY. 

tempted with this appliance the patient will usually tire out 
and quit before half the needed amount has been used. 

Syringes on the fountain pattern are right in principle. 
The water runs from the force of gravity, and the force can 
be regulated to any degree by changing the height of the 
reservoir. They do not tire the patient when she gives her 
douche to herself. It is well to remember that much force 
can be obtained by a very small stream of water. Women 
are, many of them, not acquainted with the laws of hydrau- 
lics. It is safest to caution them not to place the reservoir 
too high. The exact height had best be stated, and if pos- 
sible she should be shown just where to place it. For co- 
pious douches, one or two feet above the level of the hips is 
as high as is prudent. 

The Reservoir. — The fountain syringes formerly in use 
had the fault of a small reservoir. The largest of them had 
a bag holding but three or four quarts. More recently 
tanks have beeu made that will hold 
several gallons. The best size is not 
less than six gallons in capacity. 
These tanks are usually made of tin, 
and have an outlet near the bottom 
to which a rubber pipe can be at- 
tached. It is a convenience to have 
a stop-cock at the outlet. Figure 24 
Fis -^ ^ e ^ olds ' T ? n * is a cut of Reynolds' tank : its capac- 

and Tubing for Vaginal - 7 r 

Douche - ity is six gallons. 

The rubber tubing should be long enough for convenient 
handling. At least ten feet is required to meet ordinary 
contingencies. A cut-off should be on the tubing with 




SCANTY MENSTRUATION. 99 

which the stream of water can be controlled. It is most 
convenient to have a cut-off that is movable on the tube. It 
can then be used by the patient herself or by a nurse, as 
the case may be. The necessity of this appliance is that 
everything may be prepared before the water is turned on. 
The stop-cock at the reservoir can be opened, allowing the 
tubing to fill down to the point where it is compressed by 
the spring. After everything is arranged for the water to 
run, the catch is released without change of position. The 
stream can be stopped at any moment in the same way, thus 
placing it under perfect control. 

The Vaginal Tip. — The remaining part of the syringe is as 
important as any. It is the point to carry the water into 
the vagina. These points or tips were formerly made of 
metal. In using hot water this is a serious disadvantage, 
the metal becoming so hot as to cause much suffering. 
Water that is not hot enough to injure of itself can make a 
metal point hot enough to burn the mucous membrane with 
which it is in contact. Eecently the syringe points are made 
of hard rubber. They do not get hot, and cause no discom- 
fort from this cause. 

These points were formerly made with one opening in the 
end and several around the sides. This opening in the en: 1 
of a syringe point for the vagina is dangerous. Attacks ot 
severe pain have frequently followed their use. This pain 
is supposed to be due to the entrance of water into the 
uterus. When a stream of water strikes directly against a 
large, open cervix it is easy for some of it to be forced 
through. The pain resulting from this accident is severe, 
and frequently lasts several hours. The patient will speak 



100 MODERN GYNECOLOGY. 

of it as an attack of " cramps n in the lower abdomen which 
came on soon after the use of the syringe. The vaginal tips 
are now seldom seen with an opening in the end. But oc- 
casionally a patient will use one of the other points that 
come with her syringe. The point intended for the rectum 
is the one most frequently used in this way. Many women 
think the vaginal point too large and select the smaller one. 
When cramps follow the use of a douche it is well to inves- 
tigate the manner in which it is taken. The height of the 
tank or the point used may either of them cause the pain. 

With poor patients the matter of cost is an item of impor- 
tance. Instead of a tank and tubing, a long piece of tubing 
with a bulb near its lower end may be used with a pail or 
any receptacle for the water instead of a tank. The only 
important thing is to be sure it is large enough. The tub- 
ing is fastened over the side of the pail and a contraction of 
the bulb forces the air from the tubing. When the bulb is 
released the tubing is filled with water and a siphon action 
is started which will continue until the water is below the 
end within the pail. 

The Position of the woman while taking the douche is im- 
portant. It is also a necessity to instruct her. In almost 
every case she will use it while in an improper position if 
left to her own guidance. 

It is much more convenient for her to douche herself 
sitting over a vessel. It is impossible to reach the entire 
mucous membrane of the vagina by water injected while in 
this position. A certain amount of cleansing may be ac- 
complished in this way, but the prolonged contact of the 
water with the mucous membrane, so important at times, 



SCANTY 1VJENSTRUATI0N. 101 

cannot be obtained. The water runs out as fast as it enters 
the vagina and does not fill the canal or expand its folds. 
In order to accomplish this the patient must assume a 
position that will cause the outlet of the vagina to be its 
highest point. The position on the back with the hips 
higher than the shoulders will secure this result. The 
patient must be taught to assume this position whenever a 
douche is to be taken for the medicinal action of the hot 
water. When the douche is taken simply as part of a bath 
the vagina can be more thoroughly cleansed when the patient 
assumes the dorsal-recumbent position. And for the intro- 
duction of medicated solutions no other position will insure 
contact of the solution with all parts of the mucous mem- 
brane of the vagina. The dorsal position is even more 
important when the heat from the water is the element 
indicated as a therapeutic measure. Prolonged and inti- 
mate contact of the w^ater with the entire vagina is then 
necessary. When the pouches around the cervix are lower 
than the outlet of the vagina, the weight of the water causes 
them to enlarge and push farther back at the sides of the 
uterus. The hot water is thus permitted to surround the 
entire cervix and much of the low^er uterine segment. It 
also is brought much nearer to the appendages and the 
peri-uterine tissues. The result is that the contractions 
induced by. the heat reach all the vessels in the cervix and 
vagina, and the vessels of the deeper tissues are also caused 
to react to the heat stimulus. The uterine arteries and even 
the ovarian arteries are affected by this means. When it is 
required to drive the excess of blood from the organs sup- 
plied by these vessels the action of the hot water will cause 



102 MODERN GYNECOLOGY. 

tliem to contract, and thus the amount of blood carried 
by them is materially diminished. The contractions in the 
muscular tissues around the vessels will help to expel the 
blood from the veins at the same time. 

The effect of the hot water is greater if the contact is for 
a considerable length of time. In order to obtain this the 
flow should be slow and the quantity of water large. To 
secure a stream of water with little force and slow action 
the tank containing the water must be very little above the 
hips of the patient. The holes in the point must be small, 
for the same reason. With these conditions and a tauk 
holding six gallons, from twenty to thirty minutes will be 
consumed. 

The Bed-pan. — Having provided means of giving the 
douche properly and decided upon the correct position for 
the woman to occupy while taking it, the next consideration 
must be to provide some means of catching the water as it 
escapes from the vagina. When the patient stoops over a 
vessel or sits on one, the escape of the water is already pro- 
vided for. When she lies on her back on a bed or couch 
the water will run backward over the anus and something 
to receive it must be provided. The old-fashioned earthen 
bed-pan cannot be used when large quantities of water are 
to be used. It will not hold enough. Moreover it is a 
heavy article, and very uncomfortable to lie upon. 

Numerous light bed-pans have been devised within the 
past few years. They are made of tin or rubber-covered 
tin, and provided with means of removing the water before 
the patient gets up. The Reynolds pan is the best one at 
present in use. The pan is light in weight, it is not too 



SCANTY MENSTRUATION. 103 

high, and it can be emptied by a siphon before the patient 
rises. These are all important considerations. When the 
patient is her own nnrse the weight of a bed-pan is an item. 
These women are the ones most easily injured by lifting, 
and its necessity should be avoided. The fact that it is low 
makes it more comfortable, and the comfort of . a woman 
while taking a douche lasting a half -hour or mere should be 
considered. 

The siphon attachment to drain the pan can be used at 
either side of the pan. There are two metal tubes extending 
to the bottom at the side of the pan which goes farther up 
the patient's back, as this is the point liable to be lowest 
when the pan is in position. These tubes pass upward and 
outward along the inner surface of the sides of the pan and 
find an exit, one at each side. The end of each tube extends 
a short distance beyond the pan, and the siphon can be at- 
tached to either. 

The siphon is a short rubber tube with a bulb near its 
middle. After this is attached to the end of the metal tubing 
a contraction of the bulb 
will fill it with water and 
the water will flow as soon 
as the bulb is released. In 
using this bed-pan the si- 
phon is started after some 
water has entered the pan. Fig . a Reyno i ds1 B ed- P an with siphon 

T , .-,, , . ,, ,. Attachment. 

It will run during the tune 

of taking a douche and as long as any water remains in the 
pan. By the use of this appliance the water used can be 
carried into a vessel by the bedside and no danger of getting 




10<± MODERN GYNECOLOGY. 

the couch wet exists. Figure 25 is a cut of Reynolds' pau 
with the siphon attachment. 

The Baker bed-pan is large enough to hold six gallons. 
It has no siphon to empty it. It is high and consequently 
uncomfortable, and it may be upset in getting off it and the 
water spilled. 

The so-called French bed-pan has many of the advantages 
of Reynolds'. It is small, light, and comfortable. Instead 
of a siphon it has an exit with a stop-cock. This is not at 
the side, but at the part of the pan toward the woman's feet. 
It can be opened before the patient lies down, but is incon- 
venient to reach when the pan is in position. It is not made 
in the United States, I believe. At least I have been unable 
to find one. 

The douche appliance of Reynolds' is perfectly satisfac- 
tory in most respects. Occasionally a patient will be found 
who cannot get the siphon to work. But a little showing 
will soon make that all right. The cost is not great. 

In starting the douche the water should be allowed to flow 
into the pan until all air is expelled from the tubing. This 
also allows the water which has cooled in the tube to be ex- 
pelled. 

As has been said, the reservoir must be a very short dis- 
tance above the level of the vaginal outlet. The force with 
which the water strikes the uterus may be painful when only 
a foot or two of pressure is used. Some patients are so 
sensitive that they cannot bear a douche at all. But usually 
a few trials will enable them to take it. 

The introduction of the point into the vagina can be awk- 
wardly done. Many women are entirely ignorant of the 



SCANTY MENSTRUATION. 105 

anatomy of these parts. The end may be pushed into the 
urethra or she may be unable to get it into the vagina at all. 
Other women will imagine the vagina is too small to admit 
an ordinary vaginal tip. These are the women who use the 
rectal tip because it is smaller. When they do use the larger 
point they frequently put it in only a short distance. When 
this is the case the improbability of reaching the entire 
vagina with the water while she sits upright is greater. If 
she is in the dorsal position the vagina will be filled, even if 
the point of the syringe only enters a part of the way. A 
more satisfactory result is obtained if the tip is introduced its 
entire length. In directing the patient how to introduce the 
syringe point it is well to advise her to keep near to the per- 
ineum. She will thus avoid injuring the vestibule. Manip- 
ulation of the sensitive labia minora is also avoided. This 
latter consideration is important with very young girls, as 
onanism may be acquired in this way. Those patients who 
need local treatment for scanty or absent menstruation are 
apt to have considerable irritation around the external geni- 
talia, and consequently are in a favorable condition to ac- 
quire bad habits. The point of the syringe should always 
be anointed with oil or vaseline before it is introduced. 

The time for using the douches can be regulated somewhat 
to suit the convenience of the patient. The effects of a copi- 
ous hot douche on the circulation will last six or seven hours. 
Consequently they should be used at least twice a day. 
When only two douches are used, one should be in the 
morning and the other in the evening. The time should be 
regulated so that the patient can remain in bed for a half- 
hour or more after the douche is completed. This will give 



106 MODERN GYNECOLOGY. 

time for the weakness that frequently follows the taking of 
a large douche to pass away. If this weakness does not 
pass away before the time for using the next one, the inter- 
val must be made longer. Some patients will be so depleted 
as to impair the general health if the precautions above men- 
tioned are not taken. If any loss to the general strength 
results, the use of the hot water must be stopped at once. 
Occasionally the quantity may be made smaller than six 
gallons to advantage. 

Applications. — During the time the douche is being used 
to relieve the congestion in the pelvis, other applications can 
also be made to the vagina to advantage. About every 
fourth day the physician should make a treatment, either at 
his office or the patient's house. The patient can be treated 
while in the Sims position or in the dorsal position. If the 
Sims position is used, Cleveland's speculum can be used if 
no assistant is at hand. The ordinary bivalve is used when 
she is in the dorsal position. The result is the same in 
either case. 

When the patient is in position and the speculum in- 
serted, the first thing to do is to cleanse the mucous mem- 
brane on and around the cervix. To do this a small piece 
of cotton is grasped in the blades of the dressing forceps 
and the vagina mopped out with it. The cotton should be 
caught by the forceps in such a manner that enough of it 
projects beyond the ends of the blades to cover them and 
thus save the mucous membrane from abrasion. If the 
mucus or other substance adheres to the membrane, a small 
piece of the cotton can be dipped in the basin of warm 
water, which shoidd always be at hand, and the entire mu- 



SCANTY MENSTRUATION. 107 

eons surface bathed. When the cervix is open, its interior 
must likewise be cleansed. The plug* of tenaceous mucus, 
so frequently present in the cervix, should be removed. It 
may be necessary to dip the cotton in some solvent to re- 
move this substance. Alcohol, acetic acid, carbolic acid, or 
tincture of green soap can be tried. After the parts are 
thoroughly cleansed the application can be made. The 
medicine can be applied by grasping a very small bunch of 
cotton in the dressing forceps and dipping it in the jar con- 
taining the drug, or a small piece of cotton can be wrapped 
on the end of an applicator and used in the same way. The 
forceps will be found more convenient, and if their blades 
end in very narrow points, as they should, they will answer 
every purpose. 

The preparation used can in this way be applied all over 
the external parts of the cervix and the vaginal vaults. If 
the external os is at all open, the cervical canal should also 
be treated at the same time. If application to the endome- 
trium is indicated the uterine applicator is wrapped with 
cotton and used in the way elsewhere described. 

The substances usually applied to the vagina and cervix 
for the congestion present in scanty menstruation are those 
which produce contraction in the membrane. Tincture of 
iodine, or Churchill's tincture of iodine, is most frequently 
used for this purpose. My favorite solution for these cases 
is a solution containing equal parts of beechwood creosote 
and tincture of iodine. This mixture combines the astrin- 
gent effects of the iodine with the cleansing, deodorizing 
action of the creosote. The latter drug is also a good styp- 
tic and a counter-irritant of considerable strength. A mix- 



108 MODERN GYNECOLOGY. 

ture containing equal parts of liquid carbolic acid and tinet- 
ture of iodine can be used instead of the above solution. It 
is not quite so elegant a solution, but it is probably as effi- 
cient. Either of these mixtures can be applied to the inte- 
rior of the uterus at the same time the applications to the 
vagina are made, if such medication is indicated. If a 
more powerful counter-irritant is indicated than any above 
mentioned, the pure Monsel solution can be used. This 
can be applied generously over the vagina and cervix with 
safety, but it is not advisable to apply it beyond the inter- 
nal OS. 

After making the applications to the cervix and vagina a 
small tampon well saturated with glycerine is applied high 
up in the vagina. If there is much room in the pelvis it 
may be advisable to put one tampon at each side of the cer- 
vix in the lateral vaginal pouches. The tampons should be 
worn from twelve to twenty hours and then removed. The 
douches should be resumed after their removal. 

Depletion at the Time of the Flow. — The manner of deplet- 
ing the congested pelvic organs at the time the flow should 
come on requires some explanation. Of the use of tampons 
to withdraw the blood serum enough has already been said. 
The methods that actually remove the blood itself merit 
description somewhat in detail. They are by puncture, 
scarification, or by leeches. When it is desired to relieve 
the congestion of the uterus by puncture a knife-bladed 
tenaculum or a very narrow-bladed bistoury is used. The 
latter is easier controlled and consequently preferable. The 
blade is pushed deep into the cervix in several places around 
the external os. Care must be taken not to cut the circular 



SCANTY MENSTRUATION. 109 

artery that surrounds the cervix. Its position can be fixed 
by feeling its pulsations with the finger. 

After the punctures are made the bleeding can be encour- 
aged by a warm-water douche with a temperature less than 
105° F. It may be necessary to check the bleeding if it con- 
tinue too long. 

Scarification is done also with a bistoury, as a rule. A 
tenaculum may be used, but it is apt to make tears with 
ragged edges, which is an objection. A number of shallow 
marks or cuts are made over the cervix, sufficiently deep to 
cause oozing of blood, and then the flow is promoted by 
warm douches. Either of these methods is open to a num- 
ber of objections. The punctures may injure the tissues of 
the cervix if deep enough to cause sufficient blood to flow. 
Each method leaves a number of openings in the mucous 
membrane for the entrance of germs. In either case the 
amount of blood may be either too much or too little. 
Excessive flow is more liable to follow puncture than scari- 
fication. 

The Use of Leeches. — Professor Davenport, to whose de- 
scription of its use I am largely indebted, advocates the use 
of a leech for this purpose. His manner of using it can best 
be described in his own words : 

" For several years I have used a method by which there 
is a great saving of time and fatigue both to physician and 
patient. With the patient on the side and Sims' speculum 
in position, the cervix is well brought into view. The leech 
is then grasped with the uterine forceps about half an inch 
back from the head as it is extended, and held against the 
cervix. As a rule it takes hold almost immediately ; but if 



110 MODERN GYNECOLOGY. 

not, bringing the leech outside and taking a fresh hold will 
after one or two trials be crowned with success. At first 
thought it would seem as if the pressure of the forceps 
might so injure the leech that it would not draw as well, but 
I have found that even clasping the forceps on the neck of 
the leech is followed by no bad results. Usually it is neces- 
sary only to hold the animal firmly, gradually letting up the 
pressure as he takes hold ; but as a strong one will often 
squirm away from the forceps, it is sometimes necessary to 
clasp them. 

" If the process is watched, it will be seen that the head 
flattens out as the leech inserts its three hooklets prepara- 
tory to beginning suction, and as that is seen the pressure 
of the forceps may be diminished. If the leech does not 
show a readiness to do this, a fresh hold had better be 
taken rather than persevere with the old one. 

"It seems as if the discomfort from the pressure of the 
forceps is a stimulus which induces the leech to bite, and 
teasing it a little before introduction, so as to make it lively, 
is of help as well. Leeches vary, and of course one will be 
found now aud then which will not take hold. Occasion- 
ally, scarifying and drawing a drop of blood will prevail 
upon a reluctant leech to bite. 

"The leech being under perfect control in the grasp of 
the forceps, it is not necessary to plug the os uteri to pre- 
vent its crawling in. If it should happen, the best plan is 
to wait patiently, and within half an hour at least the leech 
will appear again. The leech should be made to bite on the 
crown of the cervix, not too near the os, nor too far over the 
side. The amount of blood lost depends upon two factors, 



SCANTY MENSTRUATION. Ill 

the capacity of the leech and the subsequent behavior of the 
bite. Leeches vary in size, and will draw from two to four 
drachms before dropping off. How much subsequently 
flows will probably depend upon the vascular distribution 
of the part where the bite is. If there is much engorge- 
ment, or if the leech happens to wound a superficial vein, 
the subsequent flowing may be so great as to occasion alarm. 
As a rule, if the patient keeps quiet the amount of blood 
lost will be sufficient to soak from two to four napkins. 
This, with the amount abstracted by the leech itself, is usu- 
ally sufficient to relieve the congestion which is the accom- 
paniment of the scanty menstruation. If the engorgement 
is very marked and the person plethoric with very scanty 
menstruation, two or even three leeches may be used with 
good effect." 

In using a leech in the method just described I find one 
change a convenience. The Sims position is necessary be- 
cause it is very tiresome to the patient to lie in the dorsal 
position long enough to apply a leech and permit it to fill 
itself. But it is also trying on the physician's assistant or 
nurse to hold a Sims speculum so long. The Cleveland 
speculum can be held indefinitely by the band across one 
shoulder and beneath the other arm. If properly adjusted 
it is not as uncomfortable to the patient as the Sims specu- 
lum, because it does not pull the perineum backward in the 
same forceful way. 

In applying a leech some precautions are needed. It 
must be understood that it is really an operation and be 
prepared for accordingly. The conduct of the patient for 
some hours afterward must be regulated with the same fact 



112 MODERN GYNECOLOGY. 

in view. In the first place, it should be done at her home, 
if possible, where she can be put to bed at once and remain 
for a while. A leech bite may cease to bleed very 
soon after the active process is over. Again, a danger- 
ous hemorrhage may result. Some people are by nature 
bleeders, and it is difficult to stop the bleeding when it 
is started. These heemophila are not apt to suffer from 
scanty menstruation. They are more prone to have men- 
orrhagia, but they may have amenorrhcea with resulting 
congestion. 

After the leech is removed the entire vagina is cleansed with 
cotton in the grasp of the dressing forceps before the specu- 
lum is removed. The patient must then he Still for several 
hours, and the amount of blood lost be kept track of by 
the napkins soiled. All clots expelled must be kept for the 
physician's inspection at his next visit. She should be seen 
in not less than ten hours after the operation, and sooner if 
possible. If it is necessary to leave her longer she should 
be instructed in methods of controlling hemorrhage. Hot 
water at 118° F. or hot water with tannin or alum can be 
advised. The recumbent position is necessary, and she 




Fig. 26. Reese's Uterine Leech. 



should be instructed how to pack the vagina with cotton, 
and several tampons should be left with her. Most of all, 
she must know the possibility of the hemorrhage being 
dangerous, and impressed with the necessity of notifying 



SCANTY MENSTRUATION. 113 

her physician in ease of its occnrrence. In cases where 
the gynecological adviser is from a distance a local phy- 
sician should be called in and requested to control the 
bleeding'. 

An artificial leech has been invented for depleting a con- 
gested uterus (Fig. 26). This instrument has the advan- 
tage of more perfect control than can be had in using the 
animal. The surgeon can select his location to apply it, 
and can regulate the amount of blood removed to suit 
the indications. 



CHAPTER V. 

MENORRHAGIA AND METRORRHAGIA. 

Uterine Hemorrhage. — Hemorrhage from the womb is an 
event of monthly occurrence in the lives of women during 
the greater part of the time from puberty to the menopause. 
The amount and character of this discharge of blood has 
already been described, and the object of the present chapter 
is to devote some attention to the excess in this flow. As 
has already been stated, women become so inured to the dis- 
charge of blood from the vagina that they view the loss 
of enormous quantities . from this source with utmost sang- 
froid, and often do not seek advice until they are thoroughly 
blanched from it. The quantity of blood which can be lost 
and recovered from is also a source of surprise to the at- 
tendants. Frail women often go on month after month 
losing excessive quantities and yet are able to be up and at 
work a considerable portion of the intervening weeks. 

An excess of the menstrual flow at the usual time is called 
menorrhagia. Hemorrhage between the periods is called 
metrorrhagia. These two conditions are frequently present 
in the same case, and at times the loss of blood becomes so 
continuous that it is impossible to decide when the menses 
do occur, or if there is any form of flow except the patho- 
logical one. When this is the case the flow is called met- 
rorrhagia. 

114 



MENORRHAGIA AND METRORRHAGIA. 115 

As a matter of convenience the two conditions will be ex- 
amined separately. It will be found that many of the causes 
producing metrorrhagia also produce menorrhagia. The 
converse of this state does not have so general an appli- 
cation. 

Menorrhagia, or too copious menstrual flow, is, like amen- 
orrhoea and scanty menstruation, a symptom of a number 
of widely differing diseases. The amount of the flow may 
only be excessive during one or more days of the period, or 
the number of days may be increased and the quantity of 
blood lost each day may be but slightly more than normal, or 
the quantity may be so great as to cause death from hemor- 
rhage. The last condition is not very common. The deplet- 
ing effects of a very free menstruation may last for a long 
time, causing anaemia and generally impaired health. This 
is more frequently produced by the cumulative effects of too 
free bleeding for a number of months. 

Menorrhagia may result from causes existing in the gen- 
erative organs, or from causes existing in the blood. 

The local causes of menorrhagia are fibroid in the uterus, 
metritis, and pelvic congestion due to any cause. Occasion- 
ally it results from inflammation in the appendages or the 
pelvic peritoneum. Any other form of pelvic congestion 
may have menorrhagia as a symptom at some time during 
its course. Uterine displacement, especially retroflexion, is 
a frequent cause of excessive menstruation. 

Carchroma of the uterus during its early stages produces 
menorrhagia. Frequently this is the only symptom com- 
plained of before ulceration commences. In the later stages 
of cancer the hemorrhages occur between the menstrual 



116 MODERN GYNECOLOGY. 

periods, and the disease frequently" reaches a stage when 
there is some blood lost each day. 

There is excessive menstrual flow present as a symptom 
of subinvolution due to retained placental remains, but as a 
rule the hemorrhage occurs between the periods as well. 

Menorrhagia from the presence of polyp or submucous 
fibroid is also frequently accompanied by metrorrhagia. 

The causes of menorrhagia will be taken up separately 
during the following pages, where this condition will occupy 
its proper position as a symptom. The treatment will also 
be given for the diseases causing this symptom. It differs 
in these several states and needs no mention here. 

In a certain number of cases of menorrhagia the excess is 
due to impaired general health. The condition is then a 
symptom of causes other than local. The chief among these 
general causes of menorrhagia are changes in the condition 
of the blood. In wasting diseases the blood may be so de- 
pleted of its normal constituents as to impair its tendency to 
form a clot. This is found in the early stages of tubercular 
disease or in anaemia from any cause. Later, amenorrhoea may 
result, but during the early stages the menstrual flow may 
be so abundant or so prolonged as to endanger the patient's 
life. The blood is thin, and coagula do not form in the bleed- 
ing capillaries to stop the period when it should end. In 
some cases it is the extreme tenuity of the tissues that allows 
the blood to ooze through. If the blood is thin it will pene- 
trate the thin- walled vessels more easily also. Probably the 
most important among the wasting diseases that occasionally 
cause the loss of too much blood at the menstrual period is 
phthisis. The menorrhagia may be the very first symptom 



MENORRHAGIA AND METRORRHAGIA. 117 

that is noticed. The early hemorrhage from the lungs them- 
selves is well known and its importance as a diagnostic sign 
appreciated. The hemorrhage from the womb occurring in 
quite young women is often of equal importance and should 
lead to an examination of the chest. 

Menorrhagia occasionally accompanies plethora. The 
tendency of stout women is usually to have too small a flow, 
but in a few cases they will have an excess at then- periods. 

Other causes of menorrhagia are purpura, scorbutus, 
Bright's disease, phosphorus poisoning, and severe jaundice. 
It may occur as a temporary condition during any of the 
acute fevers. 

Symptoms. — When the patient suffering from menorrhagia 
is seen first she is usually flowing. These patients rarely 
consult a physician during the intermenstrual period. The 
first thing to do is to learn if the amount of loss at the pres- 
ent moment is great enough to require immediate local in- 
terference. When it does, the various remedies for hemor- 
rhage of the womb should be used. They will be described 
later. If the call for local interference is not urgent, an 
attempt can be made to control the excessive flow by inter- 
nal remedies. These are frequently efficient, and when they 
fail it is in many cases due to a failure to use the one indi- 
cated. This is a state in which it will not do to rely on 
routine treatment. It cannot be safely treated as a case of 
uterine hemorrhage and that only. It must be recognized 
as a symptom and the cause discovered. Drugs that will 
control the excessive flow in a pale, thin woman will often 
be utterly useless in a stout, muscular, full-blooded one. 

There are a number of young women who lose too much 



118 MODERN GYNECOLOGY. 

blood eacli mouth that it will be advisable to try to re- 
lieve without au examination. This is particularly true of 
anaemic, poorly nourished cases. Those patients who have 
known disease of which menorrhagia is a symptom will be 
relieved of it as their general health improves. 

The Treatment of menorrhagia is with two objects in view. 
The first is treatment for the immediate hemorrhage when 
she is seen during the flow. The second is for the removal 
of the cause, and may go on at the same time as the first, 
but is more likely to be indicated during the intervals be- 
tween the periods. 

For Immediate Control of the Hemorrhage. — The treatment 
for the immediate control of a present hemorrhage claims 
attention first. The patient will be found in bed blanched 
and weak from the loss of blood. She has all the general 
symptoms of hemorrhage. It is well to ascertain how many 
napkins have been soiled and to see the amount passed in 
the form of clots. If the amount is large and the patient 
getting weaker, no time should be lost. An examination of 
the uterus must be made. If there is no evidence of history 
indicating the presence of retained placental remains or 
other foreign substance within the uterus, packing of the 
vagina should be done at once. 

Tampons. — The manner of doing this needs some descrip- 
tion. In the first place, a douche of water about 115° to 
118° F. should be given. Only a few quarts are needed. 
This will cleanse the vagina of clots and also help to control 
the hemorrhage, as will be more fully told later. After the 
douche the patient is made to lie on her side, preferably the 
left, with the buttocks as near the edge of the bed as pos- 



.MENORRHAGIA AND METRORRHAGIA. 119 

sible. She is instructed to bend up the knees and place the 
left arm behind her. The right shoulder is then pnshed for- 
ward as nearly to the bed as possible. This places her as 
nearly in the Sims position as is possible. The belt of 
Cleveland's speculum is then passed over the left shoulder 
and under the right arm and buckled there. The small 
strap is passed through the fenestra in one blade of the 
speculum and passed down the inner side of that blade 
under the metal band at the junction of the blades and back 
upon itself. It is thus in position to be drawn and hooked 
as soon as the speculum is inserted. The free blade is then 
anointed and inserted in the usual manner of inserting a 
Sims speculum. After it is in position the strap is drawn 
taut and one of its many small holes hooked on the point 
to keep it in position. The patient is now ready for treat- 
ment. 

After the interior of the vagina has been cleansed with 
cotton grasped by the dressing forceps, it should be care- 
fully inspected for possible cause of the hemorrhage. If 
bleeding points are found, a styptic can be applied directly 
to them. Usually the blood will be seen coming from the 
external os. If any indication is present, the sound and 
curette can be used at this time. It is better, however, to 
give an anaesthetic before doing a curettement. This opera- 
tion will be described in the pages devoted to metrorrhagia, 
as will the manner of using the sound and the dangers from 
its use. 

When no indication- exists for any interference with the 
interior of the uterus,- the packing of the vagina will be the 
next step in the treatment. It may be necessary to plug the 



120 MODERN GYNECOLOGY. 

cervix first with a cotton tent, but this is seldom done at a 
first packing. 

The cotton tent is made by wrapping a piece of ab- 
sorbent cotton around an applicator in such a manner as 
to make a cone-shaped plug. The ordinary uterine appli- 
cator can be used for this purpose. A special instrument is 
made that has a sliding follower on the blade, but it is not 
necessary and the applicator is always at hand when needed. 
The size of the tent must vary to suit the canal it is to fit. 
This can be seen when the cervix is inspected. The cotton 
tent must be long enough to enter beyond the internal os. 
A small thread is tied around its outer end by which it may 
be withdrawn. The tent is inserted with the applicator, 
which is then removed, leaving the cotton in the uterine 
canal. It is usually saturated in Monsel's solution of iron 
before its introduction. Any other astringent may be used, 
but the iron is probably the best. 

After the tent is in place the tampons are to be placed in 
the vagina. These tampons are usually made of absorbent 
cotton. The cotton is cut in strips about two and a half 
inches wide and then rolled into small tight pads. They 
must not be too large or they cannot be packed in tight 
enough to prevent leaking. Bach tampon is dipped in 
water containing a few drops of carbolic acid and then 
squeezed out ready for use. A thread should be looped 
around the middle of the roll of cotton to hold it in shape. 
This thread is also a convenience in removing the tampons. 
It should be double and have a knot at the end forming a 
loop, by which it can be caught to draw it from the vagina. 

In packing the vagina it is best to have a system. The 



MENORRHAGIA AND METRORRHAGIA. 121 

posterior fornix is the deepest and should receive the first 
tampon. Others can then be placed in the anterior fornix 
and then in each lateral fornix. They should be thns placed 
around the cervix until they reach the level of its end. They 
must be neatly fitted into the space around the cervix and 
firmly pressed together so as to make a compact mass. When 
the level of the cervix is reached it is often well to place a 
large flat pad of cotton directly over it and then continue 
with the smaller ones until the entire vagina is filled. "When 
the last tampon is inserted it is held in place with the dress- 
ing forceps while the speculum is removed. Care must be 
taken not to loosen the packing in drawing out the blade. 

After the vagina is packed the patient can lie over on the 
bed and remain perfectly quiet. If the treatment has been 
done under ether, or if for any other cause she has been 
placed on a table while it was done, she should be carried 
back to bed and not allowed to assist herself in any way. 

The packing should be inspected in a few hours to see if 
there has been any leaking of the blood through it. If no 
blood comes through, it can be left in for one or two days. 
If no discomfort is caused it had best remain two days. If 
the evacuation of the bowels or bladder is interfered with, a 
part of the packing may be removed to diminish the pressure 
on the rectum and urethra. The latter is more likely to be 
interfered with. 

If there is leakage of blood through the packing it should 
be removed and a fresh one put in. It may then be neces- 
sary to put the cotton tent in the cervix if this had not been 
done before. If the tent had been used a new and a larger 
one must now be inserted. 



122 MODERN GYNECOLOGY. 

In some cases there will be contraction around the vagina 
sufficient to expel the entire packing at one effort. This is 
more liable to happen when the perineal body has been de- 
stroyed during a previous childbirth. If the vagina is resist- 
ant and shows tendency to contract, sedatives may be given 
the woman to control the contractions. Valerian, aromatic 
spirits of ammonia, lavender, or sodium bromide may be of 
benefit ; but more frequently several of these in combination 
will do better. 

When the tampons fail to control the uterine hemorrhage 
the cervix may be dilated and a gauze packing placed in the 
uterus. This must be done under ether, and a thorough 
curettement should be done before the gauze is put in. The 
strips of antiseptic gauze are then carried to the fundus in 
loops. The ordinary dressing forceps can be used to intro- 
duce it. If there is a curve in the direction of the canal, 
Bozeman's forceps are better. After the entire cavity of the 
uterus is filled down to the external os, the vagina should be 
packed in the same manner as before. 

While the gauze is in the uterus the pulse and temperature 
must be watched, and at the least indication of sepsis it must 
be removed and the uterine cavity thoroughly cleansed with 
cotton pads dipped in hot water. 

Intra-uterine packing must not be permitted to remain 
as long as the vaginal packing can be left. Usually twelve 
hours is as long as is safe. The dangers are from sepsis and 
from the damming back of blood through the tubes into the 
peritoneal cavity. Each of these dangers exists with packing 
of the vagina, but not to the same extent as when the uterus 
is packed. 



MENORRHAGIA AND METRORRHAGIA. 123 

Iii a few cases of uncontrollable hemorrhage the cervix 
has been temporarily sewed up to prevent the egress of the 
blood. The pressure of the blood retained in the uterus 
against the walls causes coagula to form in the bleeding ves- 
sels and a clot is also formed within the uterus. The stitches 
must be removed from the cervix before the sides of the canal 
grow together. This is an extreme measure and is rarely 
called for. 

When the amount of the hemorrhage is less so that pack- 
ing is not necessary some of the other means of controlling- 
it can be tried. Several of these may be tried at the same 
time. Separate consideration will be given each of them. 

Hot Douches for Hemorrhage. — Probably the most impor- 
tant of these measures is the use of the hot- water douche. 
We have seen in the treatment of scanty menstruation that 
hot water has power to cause contraction of the blood-vessels 
in the tissues with which it is brought in contact. The hot wa- 
ter acts in precisely the same manner when used for the con- 
trol of hemorrhage as when used to relieve uterine congestion. 
Because of the weakness of the patient the amount of water 
used for hemorrhage is much less than for congestion. Five 
or six quarts of water at 118° F. is the usual quantity. The 
hot water must be used in the manner already detailed, but 
the patient must be moved about as little as possible in doing 
it. lb should be repeated every three hours, and three or 
four douches should show whether it is going to control the 
bleeding. If there is not a marked decrease in the amount 
of blood flow by this time some alum can be added to the 
last quart of each douche. This should cause considerable 
improvement when it has been used two or three times. In 



121 MODERN GYNECOLOGY. 

using the hot water the skin over which the water flows 
may be burned. It can be protected by a coat of vaseline. 
An ointment made of cold cream rubbed up with enough 
white wax to raise its melting point considerably is even a 
better protection. 

Ice was formerly much used to control hemorrhage, but 
the hot water has proved so much better that it is now used 
entirely. Ice-bags to the abdomen, ice- water to the vagina. 
and pieces of ice introduced into the vagina or even into the 
uterus were the means of applying the cold most in use. It 
has been discovered that the vascular contraction induced 
by heat is more lasting than that froni cold. The contrac- 
tions caused by heat will always respond to the stimulus, 
while those produced by cold are weaker at each renewal of 
the application and eventually cease to occur at all. The 
heat is much pleasant er to the patient than the cold. It 
does not have the tendency to chill her and congestive in- 
flammations do not follow its use. 

Drugs are* not to be ignored in the treatment of menor- 
rhagia. They are valuable in many cases during the time 
of the flow for its control. It is often advisable to use them 
with the hot water or other local treatment. They act in 
two ways : by stimulating contractions in the uterine muscle, 
thus lessening the caliber of the vessels, and by changing 
the blood itself, causing it to coagulate more readily. Some 
of the first class of drugs also cause the muscular walls of 
the vessels to contract and thus lessen their lumen and limit 
the amount of blood in them. 

Ergot is the drug most used to control hemorrhage by 
causing contraction of the uterine muscles. It is valuable 



MENORRHAGIA AXD METRORRHAGIA. 125 

for this purpose, though it frequently acts to better advan- 
tage when combined with others of the same class. When 
the hemorrhage is due to impaired condition of the muscular 
coat of the uterus this drug acts best. It is not beneficial 
when only the endometrium is involved. In cases due to 
intra-mural fibroid, or when the fibroid is in the transition 
stage from a mural to a submucous tumor, the effect of ergot 
is excellent. It is of uo value when the bleeding is a result 
of congestion caused by chronic inflammation in the append- 
ages or in the pelvic peritoneum. The fluid extract is the 
best form to use, the dose being from twenty drops to a 
drachm every three or four hours. No benefit is obtained 
from its use in cases where the hemorrhage is due to im- 
paired condition of the blood. 

Hydrastis canadensis is a drug of more recent introduction 
as a remedy for uterine hemorrhage. It seems to act much 
as ergot does, but is more satisfactory. Its use is indicated 
in the same class of cases, and the combination of ergot and 
hydrastis is often more efficient than either alone. The dose of 
Hydrastis is about the same as that of ergot, the fluid extract 
of both being most used. If they disagree with the stomach 
ergotin and hydrastin can be used instead. These are best 
given in tablet form. 

Quinine is a drug that induces contractions in the uterine 
muscle, and it is an excellent remedy to control hemor- 
rhage. Two or three grains of the sulphate can be given 
three or four times daily. Its antithermic properties also 
add to its value for uterine hemorrhage. If it causes no un- 
pleasant head symptoms the dose should be increased to ten 
grains. 



126 MODERN GYNECOLOGY. 

The fluid extract of hamamelis has been highly spoken of 
as a remedy of the same class as ergot and hydrastis. Alone 
it is a very inferior drug for this purpose, but it seems to aid 
the two latter drugs in their action. A combination of the 
three fluid extracts containing twenty minims of each to the 
teaspoonful can be given every three hours with benefit in 
the class of cases that respond to these drugs. 

The drugs above mentioned act directly on the muscles in 
the uterine wall. They seem to have a selective action for 
these tissues. Other drags act indirectly by stimulating the 
nervous system. Belladonna or its alkaloid atropine is the 
most efficient of the drugs that relieve uterine hemorrhage 
in this way. One two-hundredth of a grain of the sulphate 
of atropine given three times a day has relieved menorrhagia 
when ergot, hydrastis, and hot douches had all been used in 
vain. The second dose can be given in three or four hours 
after the first. 

Full doses of digitalis have been of benefit for menor- 
rhagia when given during the flow. It is indicated when 
the hemorrhage is a result of venous congestion, especially 
when the congestion is due to valvular disease of the heart. 

Acids. — Among the internal remedies which act on the 
blood itself the mineral acids are most satisfactory. Dilute 
sulphuric acid in ten-minim doses largely diluted in water 
can be given three or four times daily. It is particularly 
prompt with patients who bleed because the blood fails to 
form a clot. These women have thin, transparent skin, and 
too little strength for their ambition. They will frequently 
say they can feel the "puckering" effect of the medicine 
generally over the body after taking a few doses. 



MENORRHAGIA AND METRORRHAGIA. 12? 

Any of the other mineral acids may be used in the same 
way. The dilute sulphuric is probably the best and safest. 
It is more agreeable to take if combined with cinnamon 
water. Its use should be kept up for a few days after the 
flow ceases, or the hemorrhage may return. 

A more frequently used but less elegant remedy is galhc 
acid. It has not been as efficient as the sulphuric in my 
experience. It is not so pleasant to take. Occasionally it 
is well to combine the two acids in one mixture, their com- 
bined action being better than either in some cases. 

Tonics. — Where the menorrhagia is a result of impaired 
nutrition resulting from overwork, tonics may act promptly 
enough to stop the flow in a few days. This is more partic- 
ularly the case when the patient is anaemic. Iron is the 
tonic most satisfactory in these cases. The best form is the 
tincture of the chloride. It can be given in ten-drop doses 
every three hours for a day or more. It must be largely 
diluted in water to protect the stomach and the teeth. The 
occasional action of iron in causing hemorrhage must be 
remembered when using it. Some patients cannot take even 
a small dose without bleeding from some mucous membrane. 
The usual result of too large doses of iron is a profuse 
hemorrhage from the nose, but it may increase the uterine 
hemorrhage. 

Iron is more frequently indicated in anaemic cases to be 
taken between the periods. It is often advisable to suspend 
its use during the flow. 

Sedatives. — When the -menorrhagia is due to accidental 
causes causing injury or fright, sedatives are indicated. Ex- 
cessive or violent grief or other emotion and sudden fright 



128 MODERN GYNECOLOGY. 

may cause menorrhagia. They are more prone to do so 
when they occur just before the period should begin. The 
bromides, opiates, cannabis indica, valerian, lavender, or 
chloral can be tried, either alone or in combination. When 
opium is used it must not be continued more than a day or 
two. Full doses will act better than smaller ones. 

Rest. — The last remedy to be mentioned is probably the 
most important of all. It is rest in bed. The patient must 
be put to bed at once and made to remain there at least 
three days after the flow entirely ceases. Reclining on a 
couch will not do. The clothing must all be removed so 
that the waist and abdomen is free from all restraining gar- 
ments. She must lie flat in the bed and keep as nearly ab- 
solutely quiet as possible. All remedies used for her relief 
must be administered with as little disturbance of the patient 
as can be arranged. She must use a bed-pan to urinate and 
defecate. If she has to be moved in the bed she must be 
lifted from one side to the other and not allowed to help 
herself in any way. She must be raised to put the bed-pan 
under her and when it is removed. Of course these measures 
are not indicated in so rigid a degree where there is only an 
excessive flow each month with no danger from immediate 
hemorrhage. But even in mild cases it is safest to keep 
her as quiet as possible until the period is over. Absolute 
rest in bed for a few months may cure the menorrhagia with- 
out other treatment. 

Treatment between the Periods. — After the flow at the period, 
for which the foregoing methods were employed, has ceased, 
treatment for the condition causing it must be begun. If 
the patient is a young girl and an examination has not been 



MENORRHAGIA AND METRORRHAGIA. 129 

had during the flow, none need be made now until an at- 
tempt has been made to cure the condition by internal rem- 
edies. Iron for the anaemic, poorly nourished patient can 
now be pushed. Here, as in amenorrhcea from anaemia, 
Bland's pill is the most satisfactory form in which to admin- 
ister it. If it does not produce epistaxis or hemorrhage from 
other than the nasal mucous membrane, it can be pushed. 
Three five-grain pills after each meal will do wonders in a 
few weeks. I always order a hundred silver-coated pills at 
one time. The silver keeps them fresh, while a gelatine- 
coated pill will get so hard, when old, that it will pass through 
the entire alimentary canal without being dissolved. 

Other tonics, stomachics, plenty of nourishing food, and 
rest complete the treatment of this class of cases. The rest 
does much for girls Avho work or study beyond their strength. 
The monorrhagia is, in many cases, the result of over-appli- 
cation to study during the girl's school-life. When this is 
the case books must be eliminated from her routine for a 
number of months. Exercise in moderation must be taken, 
and fresh air in abundance must be had during the intervals 
between the menses. This is really the best kind of rest for 
the overtaxed brain and nervous system. 

If the patient is restless and irritable with sleeplessness 
she should be given bromides, lavender, or valerian. Opi- 
ates and alcoholics should be avoided. Wines are seldom of 
any benefit, usually doing more harm than good. In decid- 
ing as to the advisability of giving anything containing alco- 
hol the fact that this drug is a deoxidizer must be taken into 
consideration. It can only enter into combination by ab- 
stracting oxygen from something in its vicinity. This is 



130 MODERN GYNECOLOGY. 

usually the blood of the patient. As these women are already 
depleted of their oxygen, it is consequently the very thing 
they should avoid. 

When the patient is a married woman, or where other 
symptoms indicate its necessity, an examination of the uterus 
should be made about five days after the period is over. If 
metritis from any cause, or other condition requiring local 
treatment, be found, it will be given in accordance with the 
requirements of the case. If nothing except a heavy uterus 
and congested surrounding tissues be found, the hot douch- 
ing advised for the congestion of scanty menstruation will 
be the appropriate treatment. This can be supplemented by 
the iodine and creosote to the vagina with tampons applied 
once in five days if required. Intra-uterine applications may 
be of benefit during the time between the periods. They can 
be made at every second visit, the vagina only being treated 
at the other times. 

In treating a case of menorrhagia the previous history and 
habits of the patient must be closely studied, and any un- 
wholesome customs eliminated. If she is too active either 
with brain or body she must be guarded against the contin- 
uance of the habit. If she eats improper food it must be 
changed. Frequently her surroundings are at fault, and she 
can only improve by being removed from them. „ 

Metrorrhagia. — When hemorrhage from the uterus occurs 
between the periods it is called metrorrhagia. As has been 
said, this symptom is frequently associated with menorrhagia. 
It may be that the flow is continuous. When this is the case 
the quantity of blood lost is liable to be more at times than 
at others. The time of increased flow may coincide with the 



MENORRHAGIA AND METRORRHAGIA. 131 

menstrual period, or it may have no relation whatever to it. 
It is common to hear these patients say that they do not 
know if they have any period or not. When the period does 
occur, it can be distinguished by the feelings of the patient 
and by the menstrual odor to the blood. 

Causes. — Metrorrhagia is more liable to occur in women 
past thirty years of age. Its causes are usually grave condi- 
tions of the generative organs, and almost always in the 
uterus itself. The bleeding in some cases comes on after the 
menopause. The woman will be entirely free from uterine 
flow for a number of months or years, when it will begin 
again. The " show" may be a small daily amount, or it may 
be a loss of considerable quantity at intervals. These old 
women may feel a disinclination to mention this symptom 
because of modesty, and thus valuable time be lost. When- 
ever there are other symptoms in any way suggesting possi- 
ble uterine involvement uterine hemorrhage should be in- 
quired for. 

The causes of metrorrhagia are many of them identical 
with those of menorrhagia ; but local causes are more com- 
monly found for the former than the latter. In nearly fifty 
per cent of the cases of inter-menstrual hemorrhage some 
sloughing surface exists at the cervix or within the uterus. 
The sloughs are the result of cancer, sloughing fibroid, or 
unhealed laceration, with erosion or hyperplasia of the mu- 
cous membrane. Almost all of those cases not accompanied 
by a break in the mucous membrane are due to metritis from 
various causes. The most common causes of the metritis are 
fibroid, subinvolution, and cancer before it reaches the slough- 
ing stage. Metritis from gonorrhoea is rarely a cause of 



132 MODERN GYNECOLOGY. 

metrorrhagia. Occasional causes of metrorrhagia are uter- 
ine displacements; congestive disease of the pelvic organs 
adjacent to the uterus, and impaired condition of the blood. 
The last acts so infrequently as a cause that all others should 
be eliminated before the bleeding is attributed to it. 

All of the above-mentioned causes have received attention 
elsewhere, and the metrorrhagia has been mentioned as a 
symptom of each. The treatment has also been given, so 
that they require but brief mention here. The importance of 
metrorrhagia as a symptom of serious disease of the uterus 
will excuse a reiteration of some things covered in the other 
parts of this volume. Statistics show that more than half of 
all the cases suffering from metrorrhagia have passed their 
thirty-fifth year. By far the greatest number of these had 
cancer or fibroid of the uterus. The necessity that the treat- 
ment of both conditions should be begun at the very earliest 
moment in order to effect a radical care is the reason for an 
immediate investigation of the cause of the hemorrhage. 
The earliest symptom of each of these diseases is hemor- 
rhage, consequently no feelings of modesty should prevent 
the physician from advising an examination at once. Indeed. 
so important is this that the physician shoidd impress his 
patients with its gravity whenever opportunity offers. I 
believe it is advisable to have all women examined when 
between the ages of thirty-five and forty. An examination 
certainly should be made before the menopause. 

Abortion as a cause of metrorrhagia remains to be men- 
tioned. Small fragments of placenta remain adherent to the 
endometrium and prevent contraction of the sinuses that 
have formed there. At times even the entire placenta re- 



MENORRHAGIA AND METRORRHAGIA. 133 

mains within the litems. It may be detached entirely or ad- 
herent in part to the uterine wall. In either case hemorrhage 
results. Rarely the fetus dies in utero, but remains there 
as a foreign body. The most important symptom is hemor- 
rhage. The fetal envelope may degenerate, forming a uter- 
ine mole which may grow indefinitely until removed. The 
metrorrhagia is the most important symptom. In all cases 
of foreign body in the cavity of the uterus irregular hemor- 
rhage is the symptom which calls attention to the trouble. 
It is usually the reason the physician is consulted. 

Examination. — When a patient suffering with metrorrhagia 
is seen the advisability of an immediate examination must 
be considered first. The remarks already made in describing 
the treatment of Menorrhagia concerning hemorrhage and 
its immediate control apply here. When the loss of blood 
is an important factor it must be controlled by the methods 
there enumerated. Usually nothing is to be gained by post- 
poning the examination of patients suffering with metror- 
rhagia. There may be intervals when no blood is lost, 
but they are of uncertain occurrence. Unless the patient 
is fortunately seen when the symptom is absent nothing is 
gained by waiting, and valuable time may be lost. The his- 
tory of the duration of the discharge of blood, its character, 
and the manner in which the bleeding occurs, will give valu- 
able data to be used with the information gained from the 
examination. Cases of cancer, fibroid, metritis, subinvolu- 
tion, or laceration of the cervix will be appreciated and treated 
as is elsewhere described. Polypi will be discovered and 
removed. It is when the cause of the hemorrhage is within 
the uterus that the case needs special consideration here. 



134 MODERN GYNECOLOGY. 

The cause in a majority of these cases is the retention of the 
remains of an interrupted pregnancy. When the death of 
the fetus is recent the cervix is sometimes sufficiently dilated 
to admit a sound or even a small wire curette for the pur- 
pose of exploring the cavity of the uterus. The touch of the 
examining finger will discover an absence of cause for the 
hemorrhage at the cervix. The increased size of the uterus 
and its heavy, sodden condition will indicate that it contains 
some foreign body. The size of the cervical canal and the 
degree to which it can easily be dilated will also be learned 
at the same time. 

Exploration of the Cavity of the Uterus. — When a woman 
suffering with metrorrhagia is examined and the presence 
of a foreign body in the uterus made out, the indication is 
to explore the cavity to ascertain the size and character of 
the foreign body. If the canal is sufficiently patulous to 
admit a curette, some of the substance may be removed and 
its character made out. If doubts exist as to what the re- 
moved particles are, microscopic slides should be made and 
examined. Usually they are of such character that the diag- 
nosis is plain. When it is impossible to remove anything of 
a character to clear up the diagnosis in this way, aid of the 
sense of touch may be called for. The finger must be intro- 
duced into the uterus and its entire interior surface explored. 
Thorough dilatation of the entire cervical canal is necessary 
before this can be done. The canal must be dilated to such 
an extent that the finger can be introduced to the fundus 
and have sufficient freedom to be applied in turn to all the 
endometrium. It must not be hampered by the benumbing 
effects of a tight ring of muscle contracting upon it at the 



MENORRHAGIA AND METRORRHAGIA. 135 

internal os. Dilatation of the cervix must also be done when 
it is so closed and resistant that a curette cannot be intro- 
duced. The different methods of dilating the cervical canal 
will need some description before proceeding further. 

Dilatation for the purposes of examination are made in two 
ways. 

Tents of various kinds have been used to dilate the cervical 
canal, but their use is much less common now than formerly. 
With the knowledge of the manner of septic invasion came 
a well-founded fear that the septic inflammation so frequently 
following their use is caused by the tents. Consequently the 
most advanced teachers advise this method of divulsion with 
many precautions, and then only in a limited number of 
cases. 

A brief description of tents and the manner of using them 
is necessary. They are long narrow cylinders made of some 
substance that absorbs fluids more or less rapidly and be- 
come larger in consequence. They are usually made to taper 
slightly to aid in their introduction. 

The substances most frequently used are sponge,, laminaria 
root, and tupelo. 

Sponge tents are rough and consequently more difficult to 
introduce, but they absorb moisture very rapidly and thus 
begin to swell sooner and are less liable to be expelled be- 
fore they tighten than other varieties. They are more ap- 
propriate where the canal is already somewhat open. They 
seem to have a softening effect on the tissues, consequently 
are the best kind to use where the walls of the canal are 
rigid and the canal is not small. The sponge tent is more 
liable to be followed by septic inflammation, probably as a 



136 



MODERN GYNECOLOGY. 



result of its readiness to absorb the discharges of the vagina 
and cervix, which may be septic, also because of the difficulty 
in completely purifying the sponge itself. 

The mucous membrane forces itself into the openings of 

the sponge, and portions of it may be torn off as the tent is 

removed. The raw surfaces thus left 

are openings for the possible entrance 

of septic germs. 

Sponge tents (Fig. 27) are usually 
bought already prepared for introduc- 
tion. They should be kept in glass 
jars with air-tight lids screwed on. 
Sometimes the physician will find it 
advisable to prepare his own tents. In 
this preparation every precaution must 
be observed as to details, and no possi- 
ble opportunity for infection allowed. 

The sponge should be thoroughly 
boiled and then washed in a solution 
of bichloride of mercury, and farther 
manipulations should be done under 
Before introduction the cervix and its 
canal and the vagina should be thoroughly cleansed with an 
antiseptic solution, and douches containing corrosive subli- 
mate should be frequently used while the tent is worn. The 
vagina should receive special cleansing before it is removed. 
Sponge tents are sold in sizes and may be obtained curved 
(Fig. 28) if the direction of the canal require. They have 
been in use longer than any other variety. 

Laminaria tents are made from the roots of the laminaria 




Fig. 27. Straight Sponge 
Tent. HoIIoav. 



an antiseptic spray. 



MENORRHAGIA AND METRORRHAGIA. 



137 



digitata, or sea-tangle (Fig. 29). They are small round cylin- 
ders, and absorb liquids rather slowly, but are capable of 
exerting considerable force. They are more forcible than 
sponge tents, but do not possess the same power of softening 
the tissues. The enlargement they produce is not so great, 




Fig. 28. Sponge Tent, Curved. 



Fig. 29. Laminaria Tent. 



and they are more liable to be expelled before they have 
swelled enough to adhere to the tissues. For the same rea- 
son they do not absorb the secretions and are consequently 
less liable to become foul. There is less danger of sepsis 
from laminaria than sponge tents. 

Curved tents can be obtained and should be used if too 
much force is required' to get a straight one introduced. 

Laminaria tents should always be tried first because of 
their greater safety. They will produce dilatation sufficient 



138 MODERN GYNECOLOGY. 

for the introduction of an applicator or possibly a small 
curette, but not sufficient to admit the finger. 

The tupelo tents (Fig. 30) are also made from the root of a 
plant, the nyssa aquatica. They are found in larger sizes 
than the laminaria and do not dilate with the same amount 
of force, but they soften the tissues more. They are indi- 
cated where the canal is large and a laminaria tent would 
be liable to be expelled. They may also be used when the 
smaller variety has been used and the dilatation is not yet 



Fig. 30. Tupelo Tent. C!^I==S2^^ 

enough to permit a digital exploration. This use of a second 
tent is much more dangerous than the first one and is rarely 
indicated. A sponge tent should never be used where the 
use of two is liable to be required, as sepsis is almost certain 
to follow. The use of gradually increased sizes, forming a 
set of tents, is advised by a few authorities, but the danger 
increases with every additional one inserted. 

At times the canal at the internal os may be narrower 
than elsewhere and will admit only one tent. In such a case 
it may be well to introduce one small one through the inner 
os and pack as many others around it as can be introduced 
through the inner os without injury to the canal. These 
should not form a wedge or cone, or the canal will be un- 
equally dilated. A bundle of small smooth laminaria tents 



MENORRHAGIA AND METRORRHAGIA. 139 

can l>e tied together with a very fine thread and introduced 
all at once, and will often produce a better dilatation than 
one large tent. 

Tents should not be introduced in the physician's office, 
but at the home of the patient, where she can be put to bed 
at once and remain quiet while they are left in the canal. 

Preparation for the introduction of a tent should be made 
as for any other operation. A large airy room should be 
selected, and it should contain little furniture. There should 
be plenty of light from without, yet the windows must be 
so protected that inquisitive neighbors cannot look in. The 
upper halves of the windows give the best light. It is best 
not to have the sun shine directly into the room. The floor 
should be perfectly bare and thoroughly scrubbed and dry. 
If possible, the bed on which the patient is to lie should be 
in an adjacent room and not in the same room in which the 
operation is done. 

A small table of sufficient strength to bear the patient is 
needed. One three and a half to four feet long by three feet 
wide is large enough. It should be covered with a clean 
blanket, over which a rubber cloth is laid to protect it. These 
should both be pinned around the table feet so as to hold 
them in position. 

Le Fort dips a laminaria tent into the following solution 
just before introducing it into the uterine canal. He claims 
the dilatation will be painless. 

Iodoform 3 iij 

Cocaine pulv.. gr. lxxx. 

Sulphuric ether § iij 

M. 



140 MODERN GYNECOLOGY. 

Rapid divuhion under an anaesthetic seems more scientific 
and can be done with the entire exclusion of germs. If sep- 
tic inflammation follow such divulsion with instruments, it 
is known to be a result of failure on the part of the surgeon 
in his efforts to prevent the entrance of septic material. Sep- 
tic fever is a frequent consequence of dilatation with tents, 
occurring when every precaution seemed to have been taken. 

Dilatation of the cervical canal for diagnostic purposes 
differs in no respect from the same operation when done for 
stenosis, and has been described in the chapter on the cervix. 
The patient is placed in the Sims position and Cleveland's 
speculum used. The anaesthetic is of course given before 
the patient is placed in position or the speculum introduced. 
After the cervix is brought into view by the retractor applied 
to the anterior wall of the vagina, it is caught by a tenacu- 




Fig. 31. Skene's Tenaculum Forceps. 

lum and drawn down as far as it will readily come. The 
tenaculum used must be a strong one, or it is even better to 
use a bullet forceps or double tenaculum. It is very impor- 
tant that the hold on the cervix be a firm one. Many of 
the inflammations around the uterus that follow operation 
on that organ result from the jar caused by the slipping of 
the hold on the cervix. Skene's tenaculum forceps (Fig. 31) 



MENORRHAGIA AND METRORRHAGIA. 141 

had best be used to steady the cervix ; if a good hold be 
taken it will not slip. 

When the cervix is drawn down to an easily accessible 
position the next step depends on the condition of the canal. 
If it is so small that only a small sound or a probe can be 
introduced, Wylie's dilator is used. The Sims dilator may 
be preferred when the canal is straight, but such is seldom 
the case. Wylie's modification has a sharper curve in the 
blades and can be introduced where the Sims instrument can 
only be passed with a dangerous amount of force. Wylie's 
instrument can be introduced without difficulty into a straight 
canal. 

Having ascertained the direction of the curve by the ex- 
amination or the sound, the point of the blades is turned in 
that direction and the instrument introduced. When the 
beak has been made to enter the canal until the point is 
within the internal os, the handles are grasped firmly and 
compressed. The force used must be a steady continu- 
ous pressure. There should be no spasmodic efforts at 
stretching the canal. It is advisable to dilate in one direc- 
tion as much as can be safely done, and then allowing the 
blades to close, to turn the instrument in the canal and dilate 
in another direction. If several changes in the direction of 
the force are made, the canal will be more uniformly dilated 
and a better result obtained. Unless examination with the 
finger is required the dilating above described will usually 
suffice. It gives ample room for the use of the curette and 
the removal of small placental pieces. When the entire pla- 
centa or a fetus is within the uterus the more radical divul- 
sion must be done. 



142 



MODERN GYNECOLOGY. 



• The instrument shown in Figure 32 is the best instrument 
for complete divulsion of the cervix. It is a very powerful 
instrument, and care must be taken not to lacerate the tis- 
sues. When sloughing secundines are present it is very 




Fig. 33. Ellinger*s Divulsors. 



desirable not to cause any break in the tissues. The cervix 
can be dilated without rupture of the mucous membrane. 
In order that it remain patulous it is necessary to cause 
parting of the circular muscular fibres surrounding the in- 
ternal os. If this is not done it will contract in a very short 
time. 

When the canal is dilated and the cause of the uterine en- 
largement ascertained, the question of treatment must be 
considered. Usually this question has been decided to the 
extent of knowing that some foreign substance is within the 
uterus. In most cases it has also been decided, if found 
practical, to remove this substance when access to the cavity 
is attained. 

If the substance found in the uterus is a polyp it can be 
removed in several ways. . If the tumor can be engaged in 
the bite of a Bozeman forceps it may be detached at its pedi- 
cle by twisting. If this cannot be done a small flexible wire 
may be made to surround its attachment and made white- 



MENORRHAGIA AND METRORRHAGIA. 143 

hot by sending a galvanic current through it. This will 
remove the polyp. The chain of an ecrasenr may be intro- 
duced around the pedicle and the tumor removed in that 
way. 

In removing a polyp the important point is to get all of 
the base of the pedicle. If only a very small piece be left 
the tumor will grow again. 

If a fetus is in the uterus it can be removed with Boze- 
man's dressing forceps (Fig. 33). A regular placental for- 
ceps is made for the purpose of removing the remains of a 
gestation from the uterus. If at hand, it is very convenient 
for this purpose. Usually the fetus has been expelled when 
the case comes to the gynecologist. Placental tissues will 
be found, or it may be that the entire placenta is yet in the 
uterus. The forceps are used to remove all the larger frag- 




Fig. 33. Bozeman's Dressing Forceps. 

ments that are loose in the cavity. After this is done any 
adhering particles can be skinned off with the finger-nail if 
the finger has been introduced through the cervix. This 
also gives the benefit of the direct touch to be sure that all 
adherent tissue has been removed. For this reason many 
surgeons prefer the finger to the curette. If the latter 
instrument is used it should be the dull wire curette shown 
in Figure 34. This instrument has a small loop, so it can 
be introduced through a comparatively narrow cervical 



144 MODERN GYNECOLOGY. 

canal. It is flexible and can be bent to suit the curve 
existing in the uterus. It is safe because there is very little 
danger of cutting through the uterus with it. A sharp 
curette is seldom indicated in these cases. Its use is more 
for the removal of hypertrophied tissue or when granular 
metritis is present. The dull curette must be passed over 



Fig. 34. Thomas's Wire Curette. 

the entire interior of the uterus to be sure all adhering 
pieces are removed. The trained hand will soon recognize 
when the loop passes over a part of the endometrium that 
is not clean. The peculiar rough sensation transmitted 
through the handle of the instrument to the hand is un- 
mistakable. Adepts in the use of this instrument will not 
require any other touch to satisfy them in regard to the 
condition of membrane gone over. 

After the endometrium is entirely freed from all foreign 
substances it should be wiped over a number of times with 
absorbent cotton held in the grasp of a dressing forceps. 
The cotton should be dipped into clean hot water (120° F.) 
and wrung out until the water remaining in it will not run. 
A fresh piece should be taken each time the forceps are 
withdrawn, and the washing should be continued until the 
cotton is almost free from blood-stain when removed. 

After the interior of the uterus is washed out in the 
manner just described an antiseptic application is made to 
the endometrium. Carbolic acid, either pure or a fifty-per- 
cent solution in glycerine, should be used. The applicator 



MENORRHAGIA AND METRORRHAGIA. 145 

wrapped with a very thin coating of cotton is dipped into 
the antiseptic and carefully introduced through the cervix. 
The mucous membrane of the vagina should not be touched 
with the acid, nor shoidd it come in contact with the ex- 
ternal genitalia, as burns result from it which are painful. 
The entire surface of the mucous membrane lining the in- 
terior of the womb should be reached by the applicator. 

After the autiseptic has been applied the vagina is cleansed 
of all blood and detritus and bathed with cotton saturated 
with hot water. The speculum is then removed and the 
patient carried to bed. 

The after-treatment might be summed up in one word, 
cleanliness. This is secured by attention to details. The 
bed-linen must be clean, and the moment a part of it is 
soiled with discharges it must be removed and a clean piece 
substituted. The same care must be observed in regard to 
the patient's gowns. A soiled night-dress should be removed 
at once. The napkins must be changed at short intervals 
and never allowed to become offensive. The same care must 
be observed in cleansing the patient's person. The external 
genitals must be frequently sponged off with warm water 
containing salol, borax, or the bichloride of mercury. If 
the mercury is used it should be of a strength of one in ten 
thousand. No clots of blood must be left adhering to the 
hair covering the pudenda, and no stains of blood should 
be left on the skin underlying it. 

The vagina must be douched out frequently with boiled 
water containing some mild antiseptic. Carbolic acid should 
not be used as a rule. - The solution of bichloride used for 
bathing the external parts can be used for the douche as 



146 MODERN GYNECOLOGY. 

well. They should be warm (105° F.), and should be given 
often enough to prevent any offensive odor appearing in the 
discharges. Every third hour is the usual time for using 
the vaginal douche. The quantity of water used at eacli 
time should not exceed two quarts, as it is used for cleans- 
ing only. 

The endometrium will need to be treated after a week or 
ten days of rest in bed. This treatment will usually consist 
of application of the tincture of iodine and creosote, applied 
in the manner described in giving the treatment of metritis. 
The douches will not be required oftener than three times 
daily after the patient gets up. She should remain in bed a 
fortnight. If the metrorrhagia recurs a second curettement 
may be required, but such is seldom needed when the first 
one is done with sufficient care and thoroughness. 



CHAPTER VI. 

DISEASES OF THE VULVA. 

The vulva may be the seat of inflammation, and ulcers 
may locate here as elsewhere about the genito-urinary tract. 

Ulcers. — The favorite locations for cancer or cancroidal 
ulcers are on the inner surfaces of the labia majora, on the 
labia minora, or around the fourchette. They are also 
found in the vestibule and around the clitoris, in the folds 
of the anus, and on the outer surfaces of the great labia, and 
may rarely be found high up among the hair covering the 
mons veneris. 

Vulvitis. — Inflammation of the vulva is generally associ- 
ated with some other diseased condition of the genito-urin- 
ary tract. When it exists alone it can frequently be traced 
to some irritant, as parasites, unclean habits, or gonorrhoea! 
infection, and it may be of diphtheritic origin. In stout 
persons it may be caused by chafing from exercise in warm 
weather and perspiration. Vulvitis in very young girls is 
usually due to want of cleanliness or parasites. When due 
to want of care in cleansing the parts, the diagnosis is plain, 
as the evidences of the cause will be apparent at once on 
inspection. Vulvitis from parasites is common in children. 
It is usually associated with a vaginitis, due to the same 

cause. The most frequent cause of this condition is the 

147 



148 MODERN GYNECOLOGY. 

oxyurus vermicularis, the common thread-worm. These 
tiny parasites find little difficulty in traversing the narrow 
area of the perineum and entering the vagina. This is 
rendered more easy in small children by the presence of a 
napkin often wet or soiled. The presence of these parasites 
in the vagina acts as an irritant, and a purulent vaginitis 
and vulvitis is the result. The nurse or mother will usually 
notice this symptom first, and will seek medical advice for 
it. A careful examination of anus and vulva will usually 
reveal the cause. The parts are reddened somewhat, and 
the small threadlike parasites can frequently be seen. There 
is much itching, and the child, if old enough, will endeavor 
to scratch or rub the anus or vulva. Sometimes a mass 
of the parasites will be passed all matted together. The 
friends may think this purulent discharge is gonorrhoea! 
and fear the child has been outraged. The differential 
diagnosis is usually easy. Where the child has been mis- 
treated there is usually some evidence of injury and a his- 
tory of some kind. 

Treatment is simple. The removal of the cause is all that 
is required to effect the cure. Pure aqua calcis injected into 
the rectum and vagina is the safest and best remedy, and is 
usually all the local treatment that is needed. Cleanliness 
must be taught the nurse, and injections of a solution of the 
tincture of green soap in warm water should be given daily. 
A dose of castor-oil, followed for a few days by santonin and 
calomel in small doses three times daily, may be needed to. 
dislodge the parasites from the colon. Any simple treatment, 
as cold cream, may be applied between the labia, and will 
be more soothing if a small amount of carbolic acid has 



DISEASES OF THE VULVA. 149 

been added to it, enough to secure its anaesthetic effect as 
well as its antiseptic action. A simple decoction of quassia 
or aloes is recommended by Bartholow to be injected into 
the rectum and vagina, after the santonin and calomel have 
been taken for a day or two. lie also advises sponging the 
folds of anus and vulva with a oue-per-cent solution of car- 
bolic acid to remove ova that may be there deposited. 

Vulvitis in small children when not due to parasites is 
frequently of gonorrhceal origin. This is generally acquired 
indirectly. The manner of contagion is usually from sleep- 
ing with some one who has gonorrhoea, or from the use of 
towels and other toilet articles, or bath-tubs, etc. These 
eases are acute and chronic, the latter being often very in- 
tractable. The vulva must be thoroughly bathed several 
times daily with a one to two-thousand solution of bichlo- 
ride of mercury or boracic acid (one to twenty or stronger). 
After drying, pure powdered salol can be applied freely. If 
the vagina is involved, small suppositories of salol (one and 
a half grains) in cocoa-butter (fifteen grains) should be in- 
troduced every other day. Injections of warm water satu- 
rated with chloride of sodium, carefully made with small 
syringe, will be found efficacious in cleansing the vagina. 

Vulvitis of adults is more frequently due to irritation 
caused by discharges that bathe the parts, usually a leucor- 
rhoea or abnormal urine. If due to leucorrhcea the treat- 
ment of the cause of the leucorrhcea cures the inflamed 
vulva ; as this condition is simply a symptom of that cause 
existing higher up in the genital tract, it needs no special 
consideration here. 

Vulvitis from abnormal urine is a different matter. The 



150 MODERN GYNECOLOGY. 

condition of the urine may be temporary, in which case its 
correction and cold cream, lead ointment, or cooling washes 
will be sufficient ; but frequently the condition of the urine 
is the result of chronic disease, as diabetes, chronic nephritis 
or cystitis, the first being most troublesome because of the 
pruritis present. The condition of these women is often 
well-nigh unbearable. The sugar in the urine makes it a 
constant irritant, and its abundance makes it necessary to 
void it often. The vestibule and labia are thus brought in 
frequent contact with this irritating fluid. The resulting 
inflammation causes swelling, and so enlarges the parts that 
it soon becomes impossible to urinate without the whole 
vulva being bathed in urine. The itching present in these 
cases is the symptom most complained of, and these women 
are frequently driven almost to desperation by their inabil- 
ity to find relief. The vulvitis from a chronic cystitis and 
chronic nephritis is not so common, nor are the irritant 
effects of the urine so great in these conditions. They are 
much improved if not completely relieved by the adminis- 
tration by the mouth of drugs of sufficient amount and 
character to make the urine alkaline when voided. The 
administration of alkalies will not cure the pruritis caused 
by urine containing sugar. Alkaline urine with sugar is 
less irritant perhaps than when acid, but the sugar is the 
cause of the irritation. In diabetes it is often a long time 
before treatment can remove the sugar from the urine, and 
sometimes this is not done at all or is only accomplished for 
a brief space of time. In these cases it will become a ques- 
tion of great importance to the patient what will relieve the 
vulvitis and resulting pruritis, and that at once. The best 



DISEASES OF THE VULVA. 151 

relief will probably come from some ointment. Those hard- 
ened by wax to a consistency 7 sufficient to cause the salve to 
adhere and protect the parts will be found most satisfactory 
in preventing the nrine from causing the itching. The pru- 
ritis is best controlled by the following : 

Ac. carbol 3 ss 

Ung. rosae § ss 

M. ft. unguent. 

Sig. Apply frequently. 

The strength of this ointment (one to eight) causes the 
anaesthetic action of the carbolic acid to control the itching. 
I have never seen any unfavorable symptoms arise from it. 
The danger from absorption is slight, as the mucous mem- 
brane and skin are not usually broken, though much in- 
flamed. Its use might be dangerous in cases of advanced 
nephritis. It is perfectly safe in diabetes. The addition of 
white wax will sometimes make this ointment more efficient, 
causing it to adhere longer to the parts because of the in- 
creased hardness and greater heat required to melt it. The 
carbolic acid has been advised to be used in the form of a 
spray, using force enough to drive the fine particles of the 
solution deep into the tissues. A ten-per-cent solution is 
recommended for this purpose. The following can be used 
locally when the carbolic acid is contra-indicated : 

Aluminii nitras gr. xxiv 

Aq - ad | iv 

M. Sig. Bathe the parts once or twice a day, and use as 
a vaginal injection, 



152 MODERN GYNECOLOGY. 

The alkalinity of the urine can be maintained by the 
bicarbonate of potassium or sodium, the acetate of potas- 
sium, or the double tartrate of potassium and sodium. They 
seem to act better when given with tincture of hyoscyamus 
in full dose. The formula usually used by me is : 

Tine, hyoscyam 3 x 

Potass, acetat § j 

Aq. aurant. flor ad § iv 

M. Sig. 3 j after each meal in water. 

Other Forms of Vulvitis. — Vulvitis due to mechanical irri- 
tants or injury only requires a proper attention to cleanli- 
ness and the maintenance of an aseptic condition of the 
parts and removal of the cause. Sometimes the mucous 
glands are obstructed and a form of acne develops. The 
vulva appear as if covered with small ulcers more or less 
thickly scattered over their surfaces. These conditions are 
not common. They differ from similar inflammatory condi- 
tions in mucous membranes elsewhere only because of the 
irritant effects of mine or leucorrhcea in which they may be 
bathed. 

Treatment. — The granulations must be removed as the first 
step in the treatment. This is best done by a strong solution 
of nitrate of silver ( 3 ss to § j), or pure liquid carbolic acid, 
carefully applied to the granular surface. The labia must be 
separated by the thumb and finger of the left hand and the 
acid gently applied on a cotton swab with the right hand. 
The patient will be saved much discomfort if some vaseline 
or cold cream is applied between the labia before allowing 
them to come in contact with each other after making the 



DISEASES OF THE VULVA. 153 

application. The patient usually lies on her back when the 
application is made, and if the acid runs down over the peri- 
neum and anus a painful sore may result. This can be pre- 
vented by placing a piece of cotton at the perineum to catch 
any overflow. The after-treatment consists of cleansing the 
parts frequently, antiseptic injections into the vagina and 
rest in bed if the vulvitis be severe. The small ulcers will 
frequently yield to the treatment just described, but when 
intractable to this treatment it will be necessary to apply 
solid nitrate of silver or nitric acid to each small ulcer. 
Care must be taken to destroy each ulcer entirely and yet 
not to destroy the surrounding healthy tissue. Several sit- 
tings may be needed to effect a cure. A spray of cocaine 
(four-per-cent solution) applied a few minutes before will 
make this practically a painless operation. 

The Bartholin ian glands may inflame and suppurate, pro- 
ducing an abscess the size of a pigeon's egg. This is a very 
painful condition, and may exist a number of days before 
" breaking." Poulticing to aid the suppuration of the wall 
may hasten its rupture and expulsion, but less deformity 
will result and much suffering will be saved the patient if 
a simple incision is made opening the abscess cavity thor- 
oughly. Its contents should then be thoroughly evacuated 
and the cavity packed tightly with antiseptic gauze or ab- 
sorbent cotton, the dressing being changed daily for a week, 
by which time it will have grown so small as to be practically 
cured. 

Gonorrhoea may cause a chronic inflammation in a Bartho- 
linian duct. In such cases the duct must be laid open and 
allowed to heal by granulation. The vulva may be the seat 



154 MODERN GYNECOLOGY. 

of erysipelas. This usually follows labor, or occurs iu in- 
fants after the eruptive fevers. Gangrene of the vulva may 
occur with destruction of the parts. 

Cancer of the vulva is occasionally met with, and if found 
early enough before it has spread to involve other and deeper 
structures, it should be removed at once. Lupus, elephanti- 
asis, etc., may also occur, but are rare. The vulva may also 
be involved in irritating skin diseases, as eczema, eczema 
marginatum, or by pedicli. These all cause pruritis vulvae 
and may cause masturbation, the habit being acquired in the 
efforts to allay the itching by scratching. The unguntum 
acidi carbolici (3J to |j) will usually suffice to relieve the 
itching. Hernia into the labium majus may occur. It differs 
little from hernia in the male, except the presence of the 
spermatic vessels and chord and the testicles in the latter 
make it more serious. Hernia into the vulva must be re- 
duced and retained by a truss to avoid danger. If strangu- 
lated, the treatment is the same as in the male — reduction 
under an anesthetic or operation for its radical cure. Preg- 
nancy will add an additional danger to this condition by 
causing increased swelling. Varicose veins may occur in 
either labium majus or both. This condition is usually a 
result of pregnancy and considerable source of danger from 
possible rupture, especially at the time of delivery, and it 
may persist afterward as a chronic condition. A support 
will often be all the treatment needed, but it may require 
evacuation of the tumors and ligature of the veins to prevent 
rupture and dangerous hemorrhage. 

The condition of the clitoris should always be looked after. 
This small organ in the female may cause much inconven- 



DISEASES OF THE VULVA. 155 

ience, and numerous reflex symptoms have been relieved by 
treatment of its abnormal conditions. By remembering that 
this organ is, in the female, the chief seat of sensation in 
copulation, its importance becomes evident. Like the penis 
in the male, it has its glands and preputial covering, and is 
largely made up of erectile tissue. And like that organ, its 
prepuce may become adherent to its glands and produce all 
the train of reflex symptoms physicians are beginning to 
learn are due to this cause in the male. Smegna will form 
under the adherent prepuce, and the resulting chalk-like 
masses form an additional irritation. 

The nervous symptoms produced by the adhesions of its 
prepuce to the clitoris and its consequent irritations are 
numerous, varying in importance from nervous irritability 
to epilepsy and paraplegia. Convulsions in young girls are 
frequently cured by freeing the glands from the adherent 
prepuce just as they are eradicated by circumcision of the 
boy. The irritation at the clitoris is also a cause of nympho- 
mania in the female, and its removal will usually cure the 
habit at once. 

While the condition of the clitoris is by no means the only 
cause of the reflex symptoms mentioned above, it is certainly 
a cause, and consequently no examination of the genitalia is 
complete without this small organ is included in it. 

The treatment is to free the glands at once. This can 
usually be done under cocaine, a few minims of a four-per- 
cent solution injected into the tissues at the base of the 
clitoris being sufficient .to destroy all sensibility. The opera- 
tion is a small one and can be quickly done, a snip or two 
with the scissors and separation of the prepuce from the 



156 MODERN GYNECOLOGY. 

glands being all that is usually required. When the glands 
clitoridis have been freed, after-treatment in the form of 
frequent bathings and packing the space between the glands 
and the prepuce with absorbent cotton is required for a 
fortnight or more to prevent the adhesions from forming 
again. The packings must be continued until the glands 
begin to be covered with their normal secretion, when the 
danger of a recurrence is past. 



CHAPTER VII. 

THE URETHRA AND URINARY MEATUS. 

Women often suffer much from very simple ailments. 
This is in no respect more common than in the diseased 
conditions of their one or more inches of urethra. The 
most common diseases here are two : gonorrhoea, and pro- 
lapse of the urethral mucous membrane. Other conditions 
are impaired control of urethra or bladder, non-specific 
urethritis, etc. But these occur chiefly as symptoms or 
sequelae of other conditions. 

Prolapse of the mucous membrane of the female is com- 
mon, and few conditions can cause so much inconvenience 
from so seemingly trivial a cause. This disease is frequently 
called urethral caruncle — a condition by no means as com- 
mon as prolapse. The mucous membrane is turned outward, 
and its folds form rounded tuberosities which become swelled 
and inflamed from being irritated by the urine, and often 
surround the outlet with a fringe of mucous membrane 
which may extend a half -inch or more beyond the meatus. 
The gashed appearance presented is peculiar and charac- 
teristic, and' is caused by parts of the membrane coming 
down more than the intervening points, making small pro- 
jections separated by a point that has not become prolapsed. 

Symptoms. — A desire to void the urine frequently is a 

157 



158 MODERN GYNECOLOGY. 

usual symptom, and these patients suffer greatly from it 
because they try to retain the urine as long as possible on 
account of the pain caused by it flowing over the inflamed 
mucous membrane. The introitus is very sensitive; the 
least touch to the parts is painful. Coitus is a torture to 
these patients if they be married women, and a simple digi- 
tal examination of the vagina or the introduction of a spec- 
ulum will cause intense pain. There is much burning sen- 
sation on urinating, and frequently itching is complained of. 

Treatment of prolapse for urethral caruncle must fail to 
effect a permanent cure. I have seen cases that have been 
treated either by clipping off the projecting fringe, or burn- 
ing it off with caustics or cautery. Either plan will give 
relief lasting for a brief time only. One case treated by 
clipping several times repeated had almost the entire mu- 
cous membrane of the urethra removedo Her urethra was 
reduced to a short funnel-shaped opening, and was almost 
devoid of sphincter action. Each operation had removed 
a portion of the prolapsed membrane, which in about six 
months was replaced by more sliding down to take its 
place, to be in turn removed. 

Appreciation of the true condition makes the indications 
for treatment plain. Some plan must be found to draw 
the mucous membrane back without severing its attachment 
at the meatus. This is best done by Emmet's button-hole 
operation, making an artificial opening for the urine further 
up the urethra in the anterior vaginal wall ; one inch from 
the outlet is sufficient. 

The operation can be done with cocaine anaesthesia, un- 
less the patient is very nervous or is one of those few people 



THE URETHRA AND URINARY MEATUS. 159 

who are wanting in susceptibility to the anaesthetic action of 
this drug. 

She should be in the Sims position, the posterior vaginal 
wall being* held away by Sims' or Cleveland's speculum. A 
sound is passed into the bladder and an incision made down 
on the sound, beginning within the vagina a half-inch from 
the meatus and extending upward. The incision must pene- 
trate the urethra, but care must be taken not to wound the 
mucous membrane of the opposite side. 

The urethral mucous membrane is then caught with ten- 
acula through this opening and drawn backward toward the 
bladder, and is stitched to the vaginal mucous membrane 
at each side of the new meatus by one or more sutures, and 
in the upper and lower angles of the cut by one suture at 
each angle. 

Emmet has made a simple instrument for making this 
artificial opening. It opens as a pair of scissors. One 
blade is round, to pass into the urethra, and has a fenes- 




Fig. 35. Emmet's Urethral Button-hole Scissors. 



tra in it. The other has a blade which when closed fits 
into this fenestra. This cuts the "button-hole" much as 
the ordinary button-hole scissors are used by a seamstress 
(see Fig. 35). 



160 MODERN GYNECOLOGY. 

This operation creates a fistula connecting the urethra 
and vagina, but it is seldom that inconvenience is caused 
by it. In case such result should obtain, the fistulous open- 
ing can be closed in the usual way after it has remained 
long enough for the natural meatus to return to a normal 
condition due to its freedom from contact with the urine ; 
this usually requires from six months to a year. If the arti- 
ficial meatus is not made too far within the vagina its clos- 
ure will rarely be called for. 

Stricture of the female urethra is rare and needs little 
mention here. It can be cured by dilatation or incision, either 
of which is easy because of the accessibility of the parts. Care 
must be taken not to destroy the sphincter and cause incon- 
tinence. Gradual dilatation with sounds is most satisfactory. 

Inability to retain the urine is due to cystitis, stone in the 
bladder, disease of the cerebro-spinal system, or injury. It 
may be temporary or permanent, depending on the cause. 
The majority of these conditions are without the province of 
this volume, but some of them require brief mention here. 

Inability to control the urine from debility of the general 
system can usually be remedied by tonics, of which strych- 
nine in full doses is the best. 

Enuresis in young girls is common, and is not due to 
debility as a rule. It seems to be a neurosis, and often is 
difficult to cure. The only history is that the child passes 
the mine involuntarily when asleep. There is no want of 
control when awake. These children are often punished for 
this as a fault. The parents should be told that they cannot 
be cured in that way. Tincture of belladonna in large doses 
given on retiring will usually effect a prompt cure. Enough 



THE URETHRA AND URINARY MEATUS, 161 

must be given to dilate the pupils, and it may be necessary 
to continue its use for a number of months. Atropine sul- 
phate may be used instead, but the tincture has given me 
the most satisfactory results. If there is any irritation of 
the parts around the meatus or burning sensations on urin- 
ating, the acetate of potassium is added in sufficient amount 
to make the urine alkaline when voided. The belladonna is 
usually given in doses much too small to get its best action 
in these cases. The following prescription is the correct 
strength for a child of eight years : 

Tine, belladonn 3 vj 

Tine, hyoscyam 3 ij 

Potass, acetat \ j 

Tine, gentian, comp q. s. ad. § iij 

M. Sig. 3 j after the evening meal in water. Repeat at 
bedtime if required. 

Non-specific Urethritis is not common, and when found is 
usually accompanied by cystitis or is due to injury. It may 
be caused by sugar or other irritating substances in the 
urine. The chief symptom is usually painful micturition, 
with frequent desire to urinate. Examination will reveal a 
congested meatus, and the mucous membrane lining the 
urethra will be seen to be inflamed as far up as it can be 
exposed to view by separating its walls. 

The Treatment consists in removing the cause : curing the 
cystitis if present, preventing the elimination of sugar or 
uric acid in diabetes or the rheumatic diathesis, neutralizing 
hyper-acidity or alkalinity by drugs, and removing stone in 
the bladder if there be one. If there is a granular condition 



162 MODERN GYNECOLOGY. 

of the mucous membrane or chronic hypertrophy an appli- 
cation of nitrate of silver (one to thirty) can be made up to 
the sphincter of the bladder, or carbolic acid and glycerine, 
equal parts of each, may be used in the same way. 

If chronic cystitis is the cause the bladder may be irri- 
gated with a strong solution of the argentum nitrate and it 
allowed to flow out per viam naturam. In doing this care 
must be taken not to destroy the tissues too much, as cica- 
tricial tissue may form, causing contraction and stricture. 

Cystitis in the female differs from cystitis in the male 
chiefly in the accessibility of the bladder to treatment. This 
accessibility may cause better facilities for acquiring the dis- 
ease also. This fact is that which calls for mention here. 
In all manipulations in the genital tract the nearness to the 
urinary apparatus must be borne in mind, and care must 
be taken to avoid injury to the meatus, urethra, bladder, or 
ureters. Septic material may be carried into the bladder by 
a sound or catheter, and a case of stone in the bladder with 
a piece of vaseline for a nucleus is on record. This had un- 
doubtedly been introduced with an instrument by a physi- 
cian. A piece of absorbent cotton was recently removed from 
the bladder of a patient who had suffered from cystitis for 
ten years, the first symptoms immediately following a treat- 
ment at which an intrauterine application had been at- 
tempted. The presumption is that the meatus was mis- 
taken for the cervix and the cotton from the applicator left 
within the bladder. 

Urethritis in the female has few symptoms compared with 
this disease in the male ; when it does occur it is usually due 
to infection from a vulvitis or a vulvo- vaginitis, which may 



THE URETHRA AND URE\ T ARY MEATUS. 163 

be due to gonorrhoeal origin or not. The question of the 
character of the urethritis is dependent on the character of 
the inflammation existing in the vulva and vagina, and must 
be decided from them. 

The chief symptoms of specific urethritis in the female are 
ardor urinae and irritability of the bladder. 

On examination a yellowish drop of pus is usually found 
in the meatus, or, if not present on separating the labia, it 
can be expressed by inserting the finger within the vagina a 
short distance and pressing its palmar surface against the 
anterior wall as it is withdrawn. The vulvo- vaginitis will 
also be seen on inspection of the parts. Microscopic exam- 
ination of the pus may be made for gonococci if desired. 

Its treatment consists of the same internal remedies as are 
indicated for urethritis in the male ; the urine must be kept 
bland and alkaline or neutral, and cubebs, copaiba, salol, or 
sandal- wood oil must be given to secure their action, as they 
are expelled in solution in the urine. The importance of 
cleanliness of the vulva and vagina to prevent reinfection 
should not be overlooked, and if indicated the physician can 
make applications of sulphate of zinc, nitrate of silver, etc., 
either in the form of an injection that does not enter the 
bladder, or applied on an applicator wrapped with cotton 
and introduced to the sphincter, but no farther. 

The dependent direction and short length of the canal 
make the natural tendency of urethritis in the female be 
toward spontaneous recovery. 



CHAPTER VIII. 



DISEASES OF THE VAGINA. 



The Vagina in its normal condition is moistened by a lim- 
ited amount of acid secretion. The walls of the vagina are 
in contact, the anterior wall resting upon the posterior wall 
and not forming an open tube, as the illustrations in many 
well-known anatomies would lead us to think. Figure 36 
gives the correct relation of the vaginal walls. 

The greatest size of the canal is at its inner and upper 
end around the cervix uteri, and when not dilated there is 
only a narrow slit extending from side to side, widening 
out a little at the cervix. The anterior wall is considerably 
shorter than the posterior wall. 

The redundant mucous membrane lies in folds or wrinkles 
in the vagina when not dilated, forming rugae. There are 
also ridges or ribs caused by elevations aud depressions in 
the membrane itself. When inflated with air or water, or 
expanded by a speculum, the capacity of the vagina is con- 
siderable. The outlet is almost a vertical line, being the 
narrowest portion of the canal. 

The normal mucus is acid in reaction, said to be due to 

the presence of lactic acid. This acid is claimed by a recent 

observer to be the result of the presence of large bacilli — the 

normal bacilli of the vagina. The bacilli are always found 

164 



DISEASES OF THE VAGINA. 



165 



in normal vaginal discharges and are absent in diseased dis- 
charges. It is supposed the lactic acid is poisonous to the 
pathological germs, and it is only when the pathological 




Fig. 36. Correct Position of the Vagina. 

bacilli are in great enough quantity to destroy the normal 
vaginal germs that a diseased condition results from their 
presence. 

Abnormalities. — The vagina may be abnormal in shape or 
size, or it may be wanting in part or entirely. These abnor- 
mal conditions may be the result of injury or disease, but 
are usually congenital. Absence of vagina is not to be dis- 
tinguished from closure of the genital canal from other 
cause until an examination is made. Closure of the genital 
canal is called atresia: The symptoms of atresia are the 



166 



MODERN GYNECOLOGY. 



same, no matter if the occlusion be at the cervix or the 
hymen or due to entire absence of the canal. 

Imperforate Hymen is rarely discovered until puberty. 
Then all the initial symptoms of the awakening function ap- 
pear. The breasts enlarge, the voice deepens, and the bust 
and hips develop ; the symptoms are followed by pains in the 




Fig. 37. Imperforate Hymen, Vagina Largely Distended. 

back and pelvis, and later on by flushing of the face, head- 
ache, and general malaise and perhaps some fever. These lat- 
ter symptoms will subside in a few days, leaving the patient 
comfortable for a month or more, when they recur with 



DISEASES OF THE VAGINA. 167 

greater intensity. She has all the feelings cine to normal 
menstruation, and often more pain, and to these are added 
the symptoms due to retention of the menstrual blood, and 
there is no " show." The flow does not appear externally. 
This may go on for a uumber of months before a physician 
is consulted. 

There is little difficulty in making a diagnosis of retention 
somewhere from the symptoms, The patient will never have 
menstruated, but will have the molimen menstruate to distin- 
guish her condition from amenorrhoea due to late develop- 
ment. One very prominent symptom found when the atresia 
is at the hymen is inability to retain the urine for auy con- 
siderable time, recurring every month for a few clays and 
then disappearing until the time for the next period arrives. 
This is due to the pressure on the bladder of the retained 
blood in the vagina, Figure 37 is a drawing taken from a 
case in which the vagina was largely distended. 

If the retention is due to an imperforate hymen this mem- 
brane will be seen at once on parting the labia majora. It 
may even bulge out as a tumor, the whole vagina and uterus 
being dilated so as to form one canal filled with dark gru- 
mous fluid. It may go back through the Fallopian tubes 
into the general peritoneal cavity, causing a peritonitis. 
This complication is rare, as the cause is usually found and 
removed before the blood accumulates in sufficient quantity 
to cause it. 

The Treatment of atresia at the hymen is plain, but must be 
carefully done. The imperforate hymen must be opened. 
Some authorities advise making a very small opening and 
allowing the accumulated blood to gradually ooze away. 



168 MODERN GYNECOLOGY. 

They claim to thus avoid all danger from the entrance of 
septic germs. The condition within is most favorable for 
acquiring sepsis, and whatever course is pursued must be 
accompanied by the most rigid antisepsis. The more radical 
method is to operate, either with or without anaesthesia, and 
drain off the retained fluid at once, taking every precaution 
to avoid the entrance of poisonous germs. This operation is 
simple. The hymen is perforated and snipped away with 
scissors. If it is very thick and resistant it is best to re- 
move the entire membrane. After the fluid has drained 
away a douche of some antiseptic solution should be given. 
Bichloride of mercury one to six thousand is probably the 
best and safest solution for douches. Permanganate of 
potassium is free from danger from absorption. Carbolic 
acid is not safe because of probably being absorbed. The 
greatest care must be taken to provide for thorough drain- 
age, as very serious consequences are sure to follow if any 
of the fluid is retained anywhere within the canal. The 
shock of too sudden removal of retained blood is also to be 
guarded against if the retention is of long standing. 

Atresia. — The retention of blood may be due to an atresia 
of the vagina anywhere along its canal. In these cases it 
may not be easy to make out if a uterus is present or uot. 
Examination by the rectum will sometimes reveal that organ 
if present. If the appendages are active and the uterus is 
filled with dammed-up menstrual blood, its normal outlines 
may be so obliterated as to make it impossible to decide if 
it is a uterus or a tumor. The operation to make the 
vagina patulous will be required if the ovarian function is 
active. 



• DISEASES OF THE VAGINA. 169 

Congenital atresia without symptoms may exist, the 
uterus or ovaries being absent or inactive. In these cases 
no operative interference is indicated as a rule. Where the 
woman has married in ignorance of her inability to have the 
marriage consummated, an artificial vagina has been success- 
fully made. But such operations are seldom required, and 
their wisdom is questionable. 

If the menstrual function exists, an opening must be 
made for the exit of the blood, great care being required to 
avoid cutting into the bladder or rectum. The peritoneum 
may extend far down into the pelvis, and care must be taken 
to avoid cutting it. 

After the artificial canal is made glass tubes must be 
worn for months to keep it from contracting. A quasi- 
mucous membrane will form in time, lining the artificial 
vagina, and then it may remain patulous. But it needs 
watching, and the least tendency to contract must be com- 
bated by the daily introduction of the tube. 

Acquired atresia is usually from injury or disease. Its 
causes are contraction of cicatricial tissue, the result of heal- 
ing tears received in childbirth or from other injury, or from 
ulceration. Very hot douches may scald the mucous mem- 
brane, and the scars contracting will narrow the canal, but 
complete closure is rare for this cause. The raw surfaces 
may adhere in healing. 

Many cases of multipara are met with that have " bands " 
in the vagina. These may be simply a thickening of the 
vaginal wall at one side, causing a ridge to be felt there, or 
they may be so extensive as to almost close the canal. These 
bands usually run from the cervix, and are due to tears of 



170 MODERN GYNECOLOGY. 

that part which have been so deep as to involve the vagina 
itself. 

Rarely the vagina is torn in this way when the cervix is 
entire. The wall has been torn by the introduction of a 
hand into the vagina (Tait) or by rough coitus. The usual 
cause is childbirth. The symptoms of acquired narrowing 
of the genital canal are dependent on the amount of contrac- 
tion. If there is complete atresia there will be suppression 
of the menstrual flow. This must be differentiated from 
stoppage of this function from other causes. Pregnancy 
may be present, but can almost always be distinguished by 
associated symptoms. Cessation of the menstrual flow from 
wasting disease will be easily distinguished by the symptoms 
of that condition. The presence of all the symptoms of a 
normal menstruation without external evidence is the most 
significant symptom of complete acquired atresia, and de- 
mands an examination. 

The Symptoms of narrowing of the vagina are not many or 
characteristic. The chief cause of complaint will be the pain 
produced by the entrance of anything into the vagina. If 
the constriction is considerable coitus may be impossible. 
The introduction of a syringe tip or the examining finger 
will also cause pain. 

The usual position of acquired constriction is somewhere 
in the vagina. There may also be partial closing of the 
uterus. This is usually at or near the internal os, and will 
receive attention as stenosis. The most marked symptom 
is dysmenorrhoea. This is often a congenital condition, but 
may be acquired. 

The proper treatment is dilatation, and can be done rapidly 



DISEASES OF THE VAGINA. 171 

or gradually. Rapid dilatation must be done under anaes- 
thesia. The pressure had best be applied laterally and with 
the thumbs, and should be forcible enough to cause the con- 
strictions to break. They can be felt as they give way. No 



Fig. 38. Glass Tube (Vaginal). 

break in the mucous membrane should result. A glass tube 
(Fig. 38) should then be inserted and worn constantly for 
several days, and then gradually dispensed with in about 
two months or more. 

Dilatation may also be done gradually, either by wearing 
vaginal tubes or by tampons. The tubes are introduced 
first by the physician, and then by the patient at her home, 
and are worn for a half -hour or more each day. After a 
time a larger tube is used until the constriction is cured. 

The tampons are applied around the vagina until it is 
filled, and are worn twenty-four hours unless they give pain, 
when they should be removed by the patient, who should be 
instructed to take out one or all when the pain becomes 
severe. They must be applied every third day and their use 
continued for several months. The vagina should be painted 
with tincture of iodine and creosote before each treatment, 
and the tampons saturated with boro-glycerine solution be- 
fore introduction. Absorbent wool may be used instead of 
cotton, as it is more elastic. 



172 MODERN GYNECOLOGY. 

Vaginismus is a spasmodic contraction generally due to 
a state of hyper-asthesia of the introitns. It is met with in 
nervous women. There is no real narrowing of the canal, 
but simply a spasm of muscles whenever an effort is made 
to introduce anything into it. The spasm may come on at 
other times, being excited by cold, nervous excitement, con- 
stipation, etc. It may be so severe as to cause the patient 
to go to bed from the paroxysms of pain, which are usually 
of short duration but may recur at frequent intervals. It 
may be impossible to introduce a finger into the vagina at 
all, or even the tube of a small syringe, yet when the patient 
is put under an anaesthetic the vagina will admit a large 
speculum without any difficulty. If found in married women 
there is much pain caused by any attempts at coitus, which 
may be rendered impossible by it. The closure may be only 
a temporary spasm, which yields in a few seconds, leaving 
the parts relaxed and allowing the act to be performed with- 
out further interference. The last-mentioned condition is 
usually caused by contraction of the voluntary muscles 
around the vaginal outlet, the perineum being drawn for- 
ward in a marked degree. This contraction only lasts until 
an entrance is effected, and occurs every time an attempt 
is made to introduce a speculum or anything else into the 
vagina. 

The Treatment consists in allaying the hyper-aesthetic con- 
dition of the nervous system and building up the general 
health by tonics and exercise, with suitable intervals for rest 
when needed. The local condition must also be attended to. 
A vaginal tube must be introduced and worn a part of each 
day for a long time, until all evidence of spasm has disap- 



DISEASES OF THE VAGINA. 173 

peared. It is frequently necessary to use ether to make the 
examination, and it is also needed to get the tube in place 
the first few times. When an examination can be made 
without an anaesthetic the finger in the vagina will notice 




Bozemaivs Vaginal Dilator. 



the firm contractions of the muscles closing upon it. This 
is a very characteristic sign of vaginismus, as it is noticed 
in no other vaginal disease. When the vaginal tube has 
been introduced it is best to have it worn for several days 




Fig. 40. Bozeman's Vaginal Dilator. 



before removal, after which time it can be replaced without 
the anaesthetic. It should then be worn a part of each day 
until a cure is effected. Figures 39 and 40 are vaginal dila- 



174 MODERN GYNECOLOGY. 

tors made from hard rubber. They are less liable to break 
than the glass instrument. 

The medicinal treatment usually calls for large doses of 
iron with strychnine and quinine, if indicated. It may be 
necessary to give the bromides or asafetida • the bromide of 
soda in ten-grain doses will often produce excellent results ; 
tincture of castor fiber may be of benefit where the bromide 
fails. In fact, the treatment may be summed up by saying, 
put the patient in the best general health possible. 

Care must be taken to keep these hyper-aesthetic patients 
from the use of opium or alcohol, as there is much danger 
to them in these drugs, and their use once begun is often 
difficult to keep under control. They are the type to whom 
these drugs are most liable to be injurious and whose danger 
from habit is greatest. There are many women who resort 
to some alcoholic whenever they have pain in or about their 
genito-urinary organs. If taken in large enough quantities 
they may find temporary relief in this way, but in the end 
the effects on the general system will be demoralizing. The 
custom should be condemned by every physician. 

Vaginitis. — Inflammation of the vagina is chiefly of two 
kinds, specific (gonorrhoeal) and non-specific. Either of these 
may be acute or chronic, the latter form usually, if not always, 
being a sequence of the former. 

Gonorrhoeal vaginitis is very common. This does not 
mean that so many women have acquired it in a manner 
that would reflect in any respect upon them. It does mean 
that many men, especially in cities, have at some time had 
gonorrhoea. A prominent specialist in venereal diseases of 
men stated recently that as many as ninety-five per cent of 



DISEASES OF THE VAGINA. 175 

all the men in a community had gonorrhoea some time dur- 
ing their lives. This may be a high estimate, but it becomes 
a very serious question for the gynecologist when considered 
in conjunction with what another equally well-known spe- 
cialist in venereal diseases (Fox) has said in regard to its 
cure. He said : "I am convinced that few men who have had 
a gonorrhoea extending to the deeper portions of the urethra 
ever get so completely cured as to be sure there is no risk in 
conveying the contagion to their wives." A few pus cells 
bearing gonococci may be dislodged from any of the smaller 
ducts opening into the urethra. This comes in contact with 
a mucous membrane that is fresh ground for its spreading, 
and gonorrhoeal vaginitis is the result; his own urethral 
mucous membrane resisting the contagion from acquired 
immunity. The physician should bear in mind this possi- 
ble means of contagion, as it may enable him to allay sus- 
picions that would cause doubts on the part of both husband 
and wife, while each may be innocent of marital unfaithful- 
ness. But it also shows that few women are free from risks 
of possible contagion. 

The Symptoms of acute gonorrhoea in the female present a 
well-marked picture. There is heat and burning sensations, 
with much sensitiveness of the vagina. The entrance of a 
small speculum or an examining finger causes great pain. 
There is purulent, creamy discharge, which is usually abun- 
dant, and when the urethra is involved frequent desire to 
urinate with painful micturition is added. If the vulva be- 
comes inflamed the contact of the urine will cause smarting 
in addition to the burning sensation, due to the inflamed 
condition. The inflamed labia will also cause pain from 



176 MODERN GYNECOLOGY. 

their contact with each other, and more or less swelling is 
present. The chief object of internal medication for gonor- 
rhoea in the female is to keep the kidneys well acting, and to 
make the urine hyper-alkaline and consequently bland and 
non-irritating. Also to allay the irritability of the bladder 
and its sphincter, which causes the frequent desire to urinate. 
The following prescription has usually answered all these 
requirements : 

Tinctur. hyoscyam ^ j 

Potass, acetat 3 vj 

Tine, gentian, comp ad § vj 

M. Sig. 3 ij three times daily, in half a glass of water. 

Alkaline waters should be used abundantly, and all forms 
of alcohol prohibited. Quiet in bed is necessary, and a lim- 
ited diet should be given. 

The local treatment is of the utmost importance. This con- 
sists of thorough and frequent vaginal douches. It is neces- 
sary that these be given with the patient in the dorsal posi- 
tion. They should be copious, a half-gallon or more, and 
hot; 110° to 118° F. is the proper temperature. They 
should be taken every two or three hours. 

Many drugs have been recommended to be given in these 
douches. The most prominent is probably bichloride of 
mercury, in strength vaiying from one to two thousand to 
one to ten thousand. Acidi carbolic, (one to forty) is fre- 
quently advised. Salol (one to forty) is growing in recent 
favor. Borax or boracic acid is frequently given. These 
are all good, and usually will be found efficient. The rem- 
edy most convenient and at the same time thoroughly satis- 



DISEASES OF THE VAGINA. 177 

factory is common salt (sodium chloride), a tablespoonful or 
more to a gallon of water being the best proportion. This 
has the merit of being easily accessible, is entirely free from 
danger, and is very efficient. 

When the painful stage of the acute vaginitis has been 
somewhat allayed by the douches, some application is needed 
to the inflamed mucous membrane that is in a more concen- 
trated form than above advised. These stronger applications 
must be made by the physician and not trusted to the patient. 
The best remedy is nitrate of silver ; the solution should con- 
tain a drachm to an ounce of water, and it should be kept 
in a dark bottle. The entire area of the involved mucous 
membrane should be thoroughly covered with the solution. 
It is best applied with a small ball of cotton grasped in the 
jaws of a long narrow dressing forceps, and can be applied 
either with Sims' or a bivalve speculum. Pure tincture of 
iodine is frequently used in the same way but is not as satis- 
factory as the nitrate of silver. 

Non-specific causes of vaginitis are metritis, excessive 
coitus, dysentery, diphtheria, the exanthemata causing usu- 
ally an erysipelatous form, and parasites from the rectum. 
I have seen cases due to the invasion of the vagina by para- 
sitic skin disease, tinia versicolor, eczema, etc. 

It may be impossible to distinguish a vaginitis of non- 
specific origin from one due to gonorrhoea, so a guarded 
statement is always safest in assigning a cause. 

Acute vaginitis (non-specific) is accompanied by pain in 
the vagina, which is described as of a "burning" character. 
There are burning sensations on urinating, and frequent 
micturition if the meatus and urethra are involved j tenes- 



178 MODERN GYNECOLOGY. 

mus of bladder and rectum are common. Leucorrhoea is 
almost always present ; it may be of a thick creamy charac- 
ter, or it may be white and thin in consistency, like skimmed 
milk or whey, and is rarely tinged with blood ; if it contain 
much pus it will have a greenish tinge. The leucorrhoea 
may be irritant, involving the vulva and even the skin over 
the thighs for considerable distance in an inflammation 
caused by being bathed in it. 

Inspection reveals the vulvitis, if present, by the swelling 
of the labia. On separating the inner surfaces the lower end 
of the vagina may be seen red and swelled with inflamma- 
tion and bathed in leucorrhoea. There is usually much ten- 
derness, and considerable pain is complained of from the 
introduction of the examining finger or speculum. The 
latter will reveal the inflamed condition of all parts of the 
mucous membrane, extending over the whole vagina and 
the vaginal portion of the cervix, and at times extending 
within the cervix, involving its interior mucous membrane. 

The Treatment is the same as has been given for the spe- 
cific form. 

Chronic vaginitis may be a sequence of the acute form, 
but is frequently chronic from the beginning. It is often 
gonorrhoeal when following an acute attack, but the idio- 
pathic chronic form is usually a sequence of metritis located 
at the cervix. The symptoms are not so severe as in the 
acute form, the pain is less or may be entirely absent, the 
tenesmus is less or none, and the urinary involvement has 
usually passed away. The leucorrhoea is thinner, unless 
from uterine or tubal involvement, when it may be thick and 
ropy j but it is seldom irritating, and there is little if any 



DISEASES OP THE VAGINA. i79 

tenderness on manipulating the parts. Vaginitis of non- 
specific origin is less likely to cause complicating metritis 
and salpingitis than that due to gonorrhceal infection. 

There is also a form of follicular vaginitis occasionally 
met with. It is non-specific, and its cause is unknown. 
The inflamed points are easily made to bleed by rubbing off 
the epithelicar cells, which form but a thin layer at these 
points. The vagina may be covered with small ulcers result- 
ing from the breaking down of the follicles. This is a con- 
dition rarely found. It may be confined to the cervix, or it 
may be an extension inward of follicular vulvitis. 

Treatment of chronic vaginitis is much the same whatever 
its cause. The folds of the mucous membrane must be care- 
fully reached. This is best done with copious douches taken 
with the patient in the dorsal position. After thorough 
cleansing with the antiseptic douches local applications must 
be made. This is usually done with Cleveland's speculum, 
as less of the mucous membrane is covered by the instru- 
ment, but can be very thoroughly done with a bivalve. In 
using the latter the blades should be held apart as it is with- 
drawn, and the anterior and the posterior vaginal walls 
treated as they come in view by slipping over their tips ; in 
this manner the whole of the membrane can easily be treated. 
The strong solution of the nitrate of silver is the best remedy 
to paint the vagina with, a solution containing from a half- 
drachm to a, drachm of the silver to an ounce of distilled 
water being most frequently used. Pure tincture of iodine 
will also produce good results. 

Engleman advises what he calls the "dry method" of 
treating chronic vaginitis. He applies remedies directly to 



180 MODERN GYNECOLOGY. 

the mucous membrane in the form of powder. These can 
be blown in through a speculum but are generally applied 
on a tampon. These tampons are saturated with boro- 
glycerine and then covered with equal parts of the subni- 
trate of bismuth and powdered chalk. These are left in the 
vagina for from twelve to twenty-four hours. Iodoform can 
be added to the powder if its use is indicated. An occa- 
sional douche is also required to wash out the vagina; it 
may be of plain hot water or medicated, as seems called for 
by the condition present. 

Salol is one of the newer remedies for vaginitis, and can 
be used pure in powdered form or in a suppository contain- 
ing two or three grains of salol to fifteen grains of cocoa- 
butter. It can be applied every other day. 

Powders containing calomel will sometimes cure an in- 
flamed vagina that has proven intractable to other remedies. 
The corrosive chloride of mercury can also be used, from 
one twentieth to one thirtieth of a grain being mixed with 
fifteen grains of the oil of theobroma and applied as a sup- 
pository every third or fourth day. 

Of equal importance with the applications made directly 
to the mucous membrane by the physician are the appli- 
cations to be made in the form of douches. These must be 
taken in the thorough manner elsewhere described. The 
importance of taking douches correctly cannot be too em- 
phatically impressed. 

Douches. — There are many excellent formula? for vaginal 
douches. The most used is probably a solution of borax or 
boracic acid. Either of these may be used in solutions con- 
taining an ounce or less to the pint, or even stronger. An 



DISEASES OP THE VAGINA. 181 

ounce or more of sodium chloride in a pint of water makes 
a most satisfactory solution for vaginal irrigation. This is 
especially good for chronic vaginitis of gonorrheal origin. 
If there is no involvement of the uterine mucous membrane 
it alone will cure many cases. Its accessibility is an added 
advantage. Where astringent action is needed alum can be 
added to one of the above solutions, a half-drachm to the 
quart being the proportion most used. Where it is deemed 
best to act directly on the mucous membrane by the douches, 
the sulphate of zinc can be used, in the proportion of from 
fifteen to twenty grains to a quart of water, or the fluid ex- 
tract of hydrastis may be used, either alone or with one or 
two grains of nitrate of silver to every ounce of hydrastis. 
The sulphate of zinc can also be used in this fluid extract. 
Carbolic acid is frequently used, in strength of ten to twenty 
drops to each quart of water. Its use is contra-indicated 
where there is extensive erosion about the cervix or recent 
laceration of considerable extent. This drug is especially 
dangerous when lesion of the kidneys exists. It is never 
safe to advise a patient to use "a little carbolic acid" in 
any application to a mucous membrane. The dangers from 
absorption are genuine. If any one doubts it let him give 
a small dog a bath in a solution of carbolic acid and see 
how quickly he can kill it. 

Many vegetable substances have been used as ingredients 
of vaginal douches. The fluid extract of hydrastis has been 
mentioned. The infusion of quassia or of white-oak bark 
were formerly in high repute. Tannin is also frequently 
advised. 

Injections of lactic acid have been suggested to restore 



182 MODERN GYNECOLOGY. 

the mucous membrane to its normal state, by destroying 
the pathogenitic bacilli, and at the same time furnishing a 
favorable environment for the large bacilli of the healthy 
vagina. 

A solution of mercuric chloride, about one to four thou- 
sand, is a good antiseptic douche when indicated. 

Plain hot water (110° to 118° F.) is an excellent remedy 
for vaginitis, especially where there is much inflammation, 
the hot water causing anaemia of the mucous membrane last- 
ing a number of hours by contraction of the arterial walls 
it induces. These copious hot douches should be used in all 
pelvic diseases where it is desirable to counteract congestion 
or too free blood-supply to the parts. 

The most satisfactory method is to thoroughly paint the 
whole vagina with the nitrate-of-silver solution, and have 
copious douches of hot water and salt taken every three 
hours. It may be necessary to apply the silver a second 
time, but rarely oftener if the previous applications have 
reached the whole of the involved mucous membrane. 



CHAPTER IX. 

CERVIX UTERI. 

The Uterine Cervix is probably more frequently the seat 
of disease than any other part of the parturient canal. A 
thorough knowledge of its normal condition and of the ab- 
normal changes found in it is essential. This chapter will 
consider those conditions of cervical disease in which in- 
flammation is not an essential factor. The diseases that are 
associated with inflammation are described in the chapter 
on metritis. 

The Normal Cervix is felt as a round projection extending 
downward from the anterior wall of the vagina. Its walls 
are round, smooth, and continuous, and it points toward the 
anus. If the uterus is in normal position the cervical canal 
lies in a line from the umbilicus to the anus. The small 
rounded depression of the external os can be felt in the end 
of the cervix as a dimple. It should be round, smooth, and 
entire in the nulliparous uterus, while the opening is slightly 
oval in multipara, when no laceration exists. 

The posterior wall of the cervix is longer than the anterior 

wall because of the greater depth of the vagina at the part 

under the cul-de-sac of Douglas. In the adult female the 

cervix projects into the vagina about three fourths of an inch 

on its anterior wall and one inch on its posterior wall. It 

183 



184 MODERN GYNECOLOGY. 

must be borne in mind that this is only an approximation, 
as there is a normal variation in this respect as in the length 
of noses. 

The examining finger must note the consistency of the 
cervix — if it is too hard or too soft. Its mobility and direc- 
tion are at the same time ascertained and the relation to 
surrounding organs. Any break in the continuity of the 
rounded outline will also be perceived. 

The principal abnormalities of the cervix that call for spe- 
cial mention here are stenosis, atresia, hypertrophy, and atro- 
phy ; the most common of these is probably stenosis. 

Stenosis. — By stenosis of the cervix uteri is meant a nar- 
rowing of the lumen of the cervix, which may be at any point 
in the canal. The entire canal may be involved in this way, 
but the usual position is at the internal os. More rarely the 
constriction is at the external os. 

Stenosis may be congenital or acquired. The congenital 
form is a result of mal-development and is frequently asso- 
ciated with congenital anteflexion. Women with this form 
of stenosis usually belong to one of two types which are 
really varieties of the same type. The first of these is 
anaemic, poorly nourished, afflicted with " nerves," a poor or 
capricious appetite, and has usually more energy than endur- 
ance j the other is also anaemic, but usually stout and slug- 
gish, having little energy, and claims to eat very little. Both 
varieties suffer from constipation, anaemia, scanty or absent 
menstruation, dysmenorrhoea, and leucorrhoea, and if the pa- 
tient is married dyspareunia and sterility are usual symptoms. 

Constipation and anaemia are almost invariable accompani- 
ments of congenital stenosis. They will both be considered 



CERVIX UTERI. 185 

more fully elsewhere. The scanty or absent menstruation 
results from the anaemia and is due to the same causes. The 
dysmenorrhea that frequently accompanies stenosis is charac- 
teristic. The pain begins during the first day of the flow and 
generally before it appears, and lasts a variable time. It 
may cease altogether when the flow is well established, or it 
may last during the whole period. It is usually paroxysmal, 
resembling labor pains, and the paroxysm frequently ends 
with the passage of a clot of blood. The pain is evidently a 
result of uterine contraction stimulated by the presence of 
the menstrual blood in the uterus. The first clot may dilate 
the canal to such an extent as to allow^ free exit for the re- 
mainder of that " period/ 7 or it may contract at once, requir- 
ing fresh contractions to expel the accumulation of the next 
few hours. This causes recurring paroxysms of pain lasting 
until the flow is over. 

The leucorrhcea is generally due to cervical catarrh and is 
pale, thin, and scanty. In a woman who has not borne chil- 
dren, who suffers from dysmenorrhoea, intra-menstrual leu- 
corrhcea, and sterility if married, the length of the cervix be- 
comes important. It is frequent to find a long conical cervix 
in these cases. The long cervix is a very common accom- 
paniment of congenital stenosis. 

Treatment for the stenosis and accompanying anteflexion 
frequently fails to relieve the sterility because the abnormally 
long cervix as a factor in causing it is overlooked. The dys- 
menorrhoea may be relieved, the leucorrhcea may disappear, 
but the woman does not become pregnant. If a portion of 
the long cervix is now amputated she usually becomes preg- 
nant in a few months. 



186 MODERN GYNECOLOGY. 

The condition of the cervix is usually typical. The vaginal 
portion is generally elongated, and frequently pointed, with 
a " pin-hole " os in its extremity. The examining finger will 
detect the zone of unyielding tissue in the neighborhood of 
the internal os. The anteflexion, usually present, will be 
noted at the same time. The resistance given to attempts 
to pass a uterine probe will establish the diagnosis. 

Acquired Stenosis of the cervix is almost invariably caused 
by cicatricial tissue. It is usually the result of injury received 
in parturition, the interior of the canal being denuded of its 
mucous membrane as a result of extensive bruising and con- 
sequent sloughing. The contraction of healing lacerations 
may also restrict the lumen of the cervix. The canal has 
been left too small as a result of operation to repair lacera 
tion of the cervix, the result being an artificial stenosis. 
Stenosis may result from the formation of fibrous tissue in 
the cervix. The canal may be narrowed by pressure from 
tumors either in the cervical portion of the uterus or in the 
adjacent tissues. 

There is no peculiarity of type of patients suffering from 
acquired stenosis. Symptoms may be entirely absent, but 
dysmenorrhoea is frequent and leucorrhcea is common. This 
form of stenosis is more frequently accompanied by metritis, 
although uterine inflammation is common with the congenital 
variety. The metritis involves the entire endometrium but 
is usually more localized in the mucous membrane of the 
body. 

The diagnosis is established by the examination per vagi- 
num and by the probe. Touch will also reveal the laceration, 
cicatricial tissue, or other etiological conditions present. 



CERVIX UTERI. 



187 



»W 



The Treatment of stenosis of the cervix is chiefly mechan- 
ical. The canal must be forcibly divulged. The methods of 
divulsion of the stenosed cervical canal may be classed as 
gradual and rapid. The former method is held more in 
favor by non-surgical gynecologists j 
the latter is the favorite of most sur- 
geons. Gradual divulsion is done 
at repeated treatments 
by graduated dilators 
which come in sets, the 
best being Hank's (see 
Fig. 41). Peaslee's di- 
lators also come in sets 
(Fig. 42) and are used 
in the same way. The 
method is to pass one 
or more of the smaller 
sizes at the first treat- 
ment, as large an in- 
strument being used as 
can be borne without 
causing too much pain, 
and then to use larger 
sizes at the next visit 
and increase until the 
required degree of en- 
largement of the canal 
is attained. This will usually take a number of visits. A 
too forcible treatment may set up so much irritation around 
the cervix or uterus as to make it necessary to confine every 



Fig. 41. Hank's 
Uterine Dila- 




tor. 



Fig. 42. Set of Peaslee's 
Uterine Dilators. 



188 



MODERN GYNECOLOGY. 



other visit to vaginal applications and 
the tampons, using the dilators only 
every second or third visit. It may be 
necessary to steady the 
cervix with a tenacu- 
lum while introducing 
the dilators. After 
the dilators have 
been passed each 
time, a small appli- 
cator should be well 
wrapped with absorb- 
ent cotton and an 
application of some 
counter-irritant made 
to the endometrium. 
The best is tincture 
of iodine and creosote 
(beechwood), equal 
parts of each. Equal 
parts of carbolic acid 
and glycerine is also 
very good. After the 
intrauterine applica- 
tion is made, the tam- 
pons must be applied 
to the vagina in the 
manner already de- 
scribed. 
uterS'e Difitor 8 Rapid divulsion must 



Fig. 44. Sims 1 Uterine 
Dilator. 



CERVIX UTERI. 189 

be made under anaesthesia. Tait uses his graduated dila- 
tors, passing size after size, until the divulsion is com- 
plete, at one sitting. Divulsors are more frequently 
used which enlarge the canal by opening the blades of 
the instrument while in the canal. Wylie's is most used 
in New York (see Fig. 43). The sharp angle in the blades 
makes this instrument better than others. This curve makes 
the introduction of the instrument easier when much flex- 
ion is present. A larger instrument should be at hand, 
capable of exercising more force than Wylie's will bear, as 
cases are met that will contract at once unless a more pow- 
erful instrument is used. Sims' dilator lias heavier blades 
(Fig. 44), and can be used after Wylie's has made the canal 
large enough to admit it. But more satisfaction will arise 
from using Ellinger's divulsor (Fig. 32, page 142). This is a 
cleaner instrument than Goodell's and as strong. In order 
to get a good result the circular muscular fibers around the 
internal os must be broken thoroughly. They can be felt as 
they separate. Sudden efforts must be avoided, or extensive 
laceration may be caused by the exercise of too much force 
impulsively applied. The divulsion can be completed with- 
out breaking the mucous membrane and should be, as less 
cicatricial tissue results, consequently the stenosis is less lia- 
ble to recur. The danger of infection from the entrance of 
septic germs through the torn tissues is avoided when no 
break in their continuity is caused. As there is usually 
metritis, it is well to use a blunt curette after divulsion. 
This is indicated to remove from the endometrium any 
detritus of the retained menstrual blood. The interior of 
the uterus is then treated to an application of the carbolic 



190 



MODERN GYNECOLOGY. 



acid and glycerine, and the vagina cleansed. The carbolic 
acid must not be used copiously enough to run, and must 
all be removed from the vagina or painful burns may be 
inflicted. 

Dilatation by means of tents is rarely done for stenosis 
except to afford access to the interior of the uterus for exam- 
ination and treatment. Forms of stenosis where the canal 
is large enough to admit a tent are not cases that need 
treatment for the constriction of the cervix. The use of 
tents was formerly advised in cases with patulous canal 
but with hard, unyielding walls that resisted the entrance of 
large instruments or an examining finger. Barnes' dilators 




Fig. 45. Barnes 1 Dilators, with. Apparatus for Inflating. 



are frequently advised in these cases. They consist of rub- 
ber bags (Fig. 45), which are placed in the cervical canal and 
then forcibly enlarged by pumping water into them. The 
pump is also seen in the figure. There is no real narrowing 
of the canal in these cases, consequently they will not receive 



CERVIX UTERI. 191 

farther mention here. The use of tents is fully described 
elsewhere. 

After the canal is thoroughly dilated some mechanical ap- 
pliauce may be required to prevent contraction. A number 
of " stems " have been invented for this purpose. 

Drains and Stems. — Thomas' glass stem with a cup pessary 
to hold it in place has been described elsewhere, as well as 
the manner of its introduction. Outerbridge's drain was also 
described. Either may be introduced immediately after the 
divulsion is completed, and while worn must be carefully 
watched and frequently examined to see that everything is 
progressing as it should. The drain needs less care than a 
stem, and has been introduced many times in patients who 
started for distant parts of the country to be gone a number 
of months, and who have returned without event. 

When used to relieve dysmenorrhcea in cases of compara- 
tively slight stenosis divulsion is not required. The dys- 
menorrhoea in these cases is often caused by the endometrium, 
congested by the onset of the menstrual period, partially 
closing the internal os. The cervicla endometrium may also 
close the canal by congestion in the same manner. 

Dr. Outerbridge invented a very convenient appliance 
for the introduction of the drains in cases which do not 
require divulsion (see Fig. 46). It can be used if desired, 
but an ordinary pair of dressing forceps will answer every 
purpose. The instrument is grasped between the blades so 
that their points extend a little beyond its upper end, and 
grasped in such a manner that the upper outward bends in 
the wires are compressed by closing the forceps upon it (see 
Fig. 47). The cervix is then caught with a tenaculum and 



192 



MODERN GYNECOLOGY. 



drawn forward, while the points of the forceps blades are 
gradually pressed upward into the uterus. When the angles 
at the lower part of the drain reach the external os, they are 
steadied there by a sound or cotton stick 
and the forceps are un- 
locked and withdrawn, 
leaving the drain in posi- 
tion. If there is flexion 
Bozeman's forceps can be 
used, the curve in the 
blades being suitable for 
either anteflexion or re- 
troflexion. If the drain is 
too short it will not catch 
above the internal os, and 
is apt to be expelled with 
the next menstrual flow, 
if not before. Several 
sizes should be on hand 
and one chosen to suit the 
case. Figure 48 represents 
the drain in position in 
case of anteflexion of the 
neck. 

In cases of metritis ap- 
plications can be made to 
the endometrium without 
removing the drain. It 
also insures perfect drainage and is useful when offensive 
discharges from the uterus or tubes are present. A free en- 



'ig- 

Instrument to In- 
troduce his Drain. 



Fig. 47. Method of 
Grasping Drain in 
Dressing Forceps 
for Introduction. 



CERVIX UTERI. 193 

trance is also afforded to the spermatozoa. Should preg- 
nancy occur the instrument must be removed as soon as 
possible. Although it has been worn fifth until the month 
and removed without inter- 
rupting the gestation, it is bet- 
ter not to risk the possibility 
of causing an abortion by wear- 
ing it too long. Pregnancy 
has occurred while wearing a 
glass stem and pessary. While 
this is not likely to occur, its 
possibility is important. 

Where the stenosis is unyield- 
ing and cannot be divulsed with 
any justifiable amount of force 
an operation can be done to «%£ jtwwjMgrt^u^ 
restore the canal to a patulous Neek * 

condition. This is not so frequently needed for stenosis as 
for atresia. The operation is much similar to the discission 
done by Sims for the relief of extreme, irreducible flexion. 
The incisions may have to be carried high up into the 
uterine body, and the canal must be kept patent by some 
kind of stem to prevent cicatricial contraction or healing 
together of the denuded surfaces. 

In cases with long pointed cervix and very small external os 
amputation by removal of a cone-shaped piece from the end 
of the cervix should be done. This makes the external os 
large and leaves the cervix shorter. A stem or Outerbridge's 
drain may be worn while the sutured parts are healing, to 
prevent complete closing of the canal. 




194 MODERN GYNECOLOGY. 

Atresia at the cervix occurs rarely as a congenital condi- 
tion ; when present, the imperious point may be at either os. 
Acquired atresia is also rare. It is usually the result of heal- 
ing raw surfaces which may be caused by caustic applica- 
tions, ulceration, or mechanical injury. Extensive burns 
from caustics causing sloughs have adhered when healed and 
healing syphilitic idcers have united, causing atresia. The 
usual mechanical causes of atresia of the cervix are lacera- 
tions or sloughs from delivery and the uniting of surfaces 
denuded in operative procedures. 

The chief symptom is suppression of the menstrual flow, 
with presence of the menstrual molimena. If the atresia be 
congenital the patient will never have any menstrual flow. 
If the patient has passed the menopause when the atresia 
occurs she may have no symptoms whatever from it. 

The Treatment of atresia of the cervix has already been 
described in speaking of atresia of the upper vagina. When 
it is necessary to drain the uterus, puncture or incision is 
needed, but when the menopause has set in, operation is un- 
necessary. 

Atrophy of the cervix, if congenital, is generally due to a 
failure of development, and is usually accompanied by simi- 
lar want of development of all the genital organs. Acquired 
atrophy is occasionally found after parturition as a result of 
hyper-involution in which the uterine body shares. 

The Symptoms are amenorrhcea and diminished size of the 
cervix and uterus. There is dysmenorrhcea in many cases. 
The sound reveals a small uterus, as does bimanual and rectal 
examination. 



CERVIX UTERI. 195 

The congenital variety of atrophy is treated first by gen- 
eral remedies to increase the nourishment of the general 
system, and favorable surroundings for improved health. 
Tonics, exercise in the open air, and nourishing and easily 
assimilated food produce better results than local treatment. 
The latter consists mainly of electricity in tonic form and 
the removal of causes for dysmenorrhea if present. 

The post-puerperal atrophy is only temporary. The return 
of the functional activity of the uterus should be promoted 
by tonics, etc., as above mentioned. Hot injections and re- 
peated passing of a large sound will aid in restoring the 
uterus to its normal condition. Pregnancy may occur and 
usually cures the atrophy. 

Hypertrophy of the cervix has already had consideration 
in the chapter on metritis and prolapse. It is most fre- 
quently a consequence of laceration or abnormal growths, 
although occasionally it exists as a congenital condition. The 
cases not due to metritis, with or without laceration or neo- 
plasms in the cervix or body of the uterus, are very rare, and 
are generally due to congenital deformity. The cervix may 
be enlarged in its vaginal portion or in the super-vaginal 
portion. The enlargement may be due to growth of the 
mucous membrane and the production of new glands with 
resulting softening from degeneration. This variety is dis- 
tinguished by the softness to the touch that is present, The 
other form of hypertrophy is due to the over-production of 
connective tissue, and is distinguished by its hardness. 

The Symptoms are dysmenorrhcea if the enlargement brings 
the cervix low in the- vagina, dyspareunia when it is large 



196 MODERN GYNECOLOGY. 

enough to interfere with coition, pain in the pelvis, metror- 
rhagia, and leucorrhoea. 

The Treatment is amputation of the intra- vaginal portion, 
usually by conical incision. The supra- vaginal portion will 
usually undergo a process similar to involution after the 
operation has been done, thus effecting a cure. 



CHAPTER X. 



METRITIS. 



Inflammations of tlie uterus are among the most common 
conditions of disease found in the pelvis. Subdivisions have 
been made into various kinds of uterine inflammations, but 
they are usually refinements of pathological differentiation 
and consequently of little value to the practitioner, as they 
can rarely be defined clinically. A simpler classification is 
better for practical work. 

The term metritis has been applied to inflammation of the 
uterine tissue, the term endometritis being used where the 
mucous membrane only was involved. It seems better to 
call all inflammations of the uterus metritis, and the term 
will be so used here. Corporeal inflammation without in- 
volvement of the mucous membrane is rarely if ever found, 
the involvement of the muscular tissues being a sequence 
of that of the endometrium. The mucous membrane lining 
the interior of the cervix may be involved alone, but is al- 
most always involved when that of the uterine body is, conse- 
quently both are parts of one condition, and their description 
together avoids much repetition. Metritis is most frequently 
a sequence of either gonorrhoea or the puerperal state. 

Gonorrheal Metritis. ,^That from gonorrhoea may begin as 

an acute vaginitis, in which the uterus may or may not par- 

197 



198 MODERN GYNECOLOGY. 

ticipate, or it may come on without any history of acute 
symptoms. This latter form is usually acquired from an 
attenuated infection, as from a gleet, or from an old sup- 
pressed and supposed to be cured gonorrhoea in the male. 
In either case the vulva and vagina are usually first involved, 
then the cervix, and finally the whole interior of the uterus, 
whence its course to the Fallopian tubes is rapid. 

Puerperal Metritis. — The infection producing metritis from 
puerperal causes may also come from without, but its manner 
of entry is different. The germs are probably from the va- 
gina and cervix, and the subinvoluted uterus, with or without 
placental remains, forms a suitable nidus for their reception. 
The vagina and cervix up to the internal os probably con- 
tain more or less pathological germs at all times. An ab- 
normally patulous cervix may admit these to the uterine 
cavity to set up inflammation there. The presence of pla- 
cental or other tissues remaining from a pregnancy prevents 
the uterus from resuming its normal size after delivery. This 
is much more apt to occur after abortion than delivery at 
full term. This subinvolution may also result from getting 
up too soon after the expulsion of the fetus, or from instru- 
mental interference for its removal. The uterus may assume 
an abnormal position causing congestion and preventing in- 
volution. The entrance of germs is necessary in conjunction 
with one of the above-mentioned conditions to produce me- 
tritis. These may be carried in by unclean hands or instru- 
ments, or may enter as a result of carelessness in cleansing 
the external genitalia, or failure to keep the vagina in an 
aseptic condition during the puerperal period. 

Other Varieties. — Metritis may be caused by the passage 



METRITIS. 199 

of a sound, or the entrance of germs from the vagina in a 
non-puerperal state, or germs may be forced into the uterine 
cavity by an improperly used vaginal douche. The latter 
accident is most frequently caused by using a douche tip 
with a single opening directly in the end, allowing the stream 
of water to strike the external os with force and volume 
enough to enter the uterus. The germs may also enter by 
closure of the external os while the plug of the contaminated 
mucus remains in the cervix, and is forced into the uterus, 
setting up septic inflammation. This accident usually occurs 
about the time of the menstrual flow. 

Metritis in Single Women. — There is a form of metritis 
found in single women due to a variety of causes. The most 
common among these are excessive dancing or other violent 
exercise during menstruation, the use of machinery worked 
by foot power, as the continuous running of a sewing-ma- 
chine, running up and down stairs, standing on the feet for 
long periods, or anything that tends to keep the uterus con- 
gested, and thus in a favorable condition for the entrance 
of septic elements. 

All these forms of metritis, except occasionally the gonor- 
rhoea!, are chronic when they come under observation. It 
has not been determined whether they had an unappreciated 
acute form preceding the chronic condition or not, but most 
authorities maintain that metritis is often chronic from the 
start. 

Results of Metritis. — Metritis rarely results in spontaneous 
cure. The tendency is to continue. Davenport claims that 
the congestion present causes a growth of connective tissue 
which by contracting eventually lessens the caliber of the 



200 MODERN GYNECOLOGY. 

blood-vessels and produces atrophy of the muscular tissue. 
This converts the uterus into a fibrous body, and if uninter- 
rupted would cause the " atrophic metritis " of Skene. 

A more common result of metritis is extension of the in- 
flammation to the tubes, causing salpingitis, frequently to 
be followed by peri-salpingitis and ovaritis. The gonorrhceal 
and puerperal forms are more likely to extend to the append- 
ages than the other varieties, and the results there are more 
serious. In these forms the pelvic inflammation more fre- 
quently causes abscess with a general peritonitis as a frequent 
result, and fatal terminations are not infrequent. 

Metritis limited to the cervix always results from a vag- 
initis. Cervical metritis of puerperal origin is always ac- 
companied by inflammation of the body as well, though the 
latter may be present in a mild form. When there has 
been laceration or much bruising of the cervix during labor, 
causing sloughing or erosion, the whole uterine mucous mem- 
brane is more or less the seat of inflammation. The inflam- 
mation of the cervix in these cases is largely in excess of that 
higher up in the uterus, but it must be borne in mind that 
the uterus anatomically includes the cervix, and there is sel- 
dom, if ever, inflammation of one part to the entire exclusion 
of the other. 

Metritis Chiefly in the Cervix. — It is well, however, to 
devote some space to the special description of conditions 
in which the inflammation is chiefly localized in the cervix. 
Where the metritis has persisted in the cervix for a length 
of time it may invade all the structures, involving, step by 
step, the muscular and fibrous portions, and causing hyper- 
trophy. 



METRITIS. 201 

The form of metritis in which the cervix is most involved 
may be attended by laceration, erosion, e version, hypertro- 
phy, congestion, granulations, cysts, etc., either as cause or 
result of the inflammation. 

Erosions are frequently seen in cervical metritis. They are 
usually found at the side of the external os, covering a larger 
or smaller space on the crown of the cervix ; sometimes the 
os is entirely surrounded by the eroded area. The appearance 
presented is that of a patch, usually round or oval, darker in 
color than the mucous membrane surrounding it. It may be 
slightly depressed, showing an abrupt line of demarkation, 
but more frequently there is a gradual shading from the dis- 
eased to the healthy tissue. These eroded patches are often 
covered with adherent mucus, but they may present a glazed 
appearance when the secretions from the surrounding vagina 
or the interior of the cervix are removed. 

A congenital tendency to erosions is claimed by some 
authors, who also claim a corresponding immunity to exist 
in other cases. That it is a condition frequently found in 
young unmarried women favors the claims of hereditary 
tendency. 

Erosion of the cervix is always associated with cervical 
metritis, and usually vaginitis is present. The uterine cer- 
vix is often eroded by irritant discharges from the uterine 
cavity ; it may also result from mechanical injury received 
during copulation or from a roughly used syringe tip. The 
initial cause of the erosion may vary, but the condition is 
kept up indefinitely by. irritant uterine secretions from the 
metritis within, or the^secretions of the vagina itself, if they 
are at fault. 



202 MODERN GYNECOLOGY. 

This condition is very frequently spoken of as " ulceration 
of the womb." It is certainly a misnomer to call these eroded 
patches ulcers, because there is no true ulcerative process. 
True ulcers may form on the cervix, but they are rare, and 
when they occur are usually specific, cancers or cancroids, 
or due to a follicular inflammation in which there is granu- 
lation associated with numerous small ulcers. When this 
raw surface is found on the cervix of a nulliparous uterus 
it indicates either metritis of congestive origin, or, which is 
more common, a metritis of gonorrhoeal origin with existing 
or impending gonorrcehal salpingitis. The nature of the dis- 
charge will usually tell which it is. If the discharge coming 
from the external os is yellowish, thick, and tenacious, form- 
ing a plug in the cervical canal, it is almost always gonor- 
rhoeal. When the metritis is of congestive origin there is 
more local tenderness, the uterus and cervix being painful. 
Gonorrhoeal metritis may exist without pain. Erosion on the 
cervix of a parous uterus may come from either of the above 
causes, or it may be due to inflammation of the endometrium 
due to retained placental fragments within the uterus. This 
form may also have an accompanying tubal involvement due 
to the same cause. 

Cysts may be present in the cervix, complicating, metritis. 
They consist of small, round, translucent masses that are 
usually hard, devoid of fluctuation, and slightly bulging 
above the surrounding tissues, though they may be so deeply 
imbedded in the cervix as not to present the last-named 
symptom. When punctured they are found to contain a clear 
fluid slightly thicker than water in consistency. The whole 
cervix may be studded with them, or there may be but two 



METRITIS. 203 

or three. Their tendency is to increase in number, and they 
refill when punctured. 

Ever s ion. — The mucous membrane of the cervix may be- 
come everted. This usually occurs more on one side of the 
external os than on the other, and frequently is all on one 
side. It may or may not be associated with laceration. 
Where no laceration exists there presents a roundish mass 
at one side of the os and partially encroaching upon its lumen. 
This mass is slightly raised above the surrounding parts and 
is covered with granulations. It is usually darker in color 
than the surrounding cervix. When touched with an appli- 
cator or probe it frequently bleeds freely. In these cases it 
is usually a formation of new tissues and not a true turning 
out of the cervical mucous membrane. 

When eversion is found with laceration it is usually a se- 
quence of that condition. The gaping of the torn parts al- 
lows the endocervical mucous membrane to become prolapsed. 
This is further provoked by hypertrophy resulting from the 
inflammation which follows the laceration. The laceration 
may be concealed by the fact that it does not extend to the 
external os, the tear being produced from within outward. 

Hypertrophy of the cervix is always present with laceration, 
and will be spoken of again under lacerations. There is an 
hypertrophy found with cervical metritis where no laceration 
exists. This condition has already been spoken of. The in- 
flammatory process extends from the endocervical mucous 
membrane to the deeper tissues, causing congestion, which is 
usually followed by increased production of connective tissue, 
causing a true hypertrophy. Hypertrophy occurs at times 
with elongation of the cervix, complicating that condition. 



204 MODERN GYNECOLOGY. 

and may have been an etiological factor in its production. 
Figure 49 is taken from a case in which there was hyper- 
trophy of the cervix. 




Fig. 49. Hypertrophy of the Cervix. 

Laceration of the cervix is either the result of parturition 
or mechanical interference. The latter cause is not common, 
but the cervix has been torn in efforts at a rapid divulsion. 
The usual cause of a laceration is delivery of a fetus, either 
by instruments or without them. Cases of laceration caused 
by the expulsion of a two-months fetus are on record. While 
this early abortion is a fruitful source of metritis, laceration 
is not so common from it as from the exit of a larger- fetus. 



METRITIS. 205 

A by no means uncommon condition is laceration at the 
inner os extending a variable distance down the cervix but 
not involving the external os. In these cases the external os 
dilates sufficiently to permit the passage of the presenting 
part, while the tissues around the internal os are unyielding 
and are torn. These cases of " concealed " laceration are at 
times very puzzling. They are more apt to occur where there 
has been a stenosis and hardening around the inner os with 
a flexion. 

Lacerations vary from a slight depression in one side of 
the cervix to complete rupture extending through the whole 
length of the canal or even above the internal os. They may 
be single, bilateral, or stellate, and may extend so as to in- 
volve the vaginal roof. The result is a metritis with hyper- 
trophy j erosion or eversion may follow, or both hypertrophy 
and erosion may result. The effort .at spontaneous cure 
forms a cicatricial plug, which is usually hard and unyield- 
ing. This plug of inelastic scar tissue causes many of the 
symptoms, and the treatment which removes it is most suc- 
cessful in relieving the symptoms. Its presence is a fruitful 
cause of deeper laceration in subsequent deliveries, because 
this cicatricial tissue forms an obstacle to dilatation. It is 
also a frequent cause of abortion. 

Lacerations followed by erosion or " ulceration " can only 
occur where there has been contact of septic material either 
from the external air, vaginal secretions, or unclean manipu- 
lation. Where there is perfect asepsis the torn surface heals 
over with a membrane similar in all respects to the normal 
mucous membrane of the cervix ; there may remain some de- 
formity from the tear, but no metritis of cervix or body is 



206 MODERN GYNECOLOGY. 

found where septic material has been kept from effecting an 
entrance. This fact shows the importance of aseptic deliv- 
eries, either at full term or before the fetus has completed its 
period of utero- gestation. 

Pozzi describes a " pseitdo-metritis " occurring with disease 
of the ovaries, tubes, or with pelvic peritonitis arising from 
scars in the broad ligaments following removal of the ap- 
pendages. He defines it as an inflammation of the uterine 
mucous membrane which is " merely an epi-phenomenon of 
tardy development, and not appearing at the first onset, 
which becomes evident only after the appearance of disease 
in the adnexa or the pelvic peritoneum." This condition is 
that of a sequence usually, and needs no further special 
mention. 

Metritis also occurs with fibroma, probably causing the 
hemorrhage, and with carcinoma at the cervix or in the body 
of the uterus. These complications need no special consid- 
eration here. 

A " membranous " metritis is described by some authors in 
which a perfect cast of the endometrium is passed at the 
time of the menstrual flow ; it is frequently called membra- 
nous dysmenorrhea; it is a rare condition. A granular 
form has also been mentioned, but cannot be distinguished 
clinically. 

The Symptoms of metritis vary with the stage of the dis- 
ease, and may also be influenced by the cause of the inflam- 
mation. 

The majority of cases give a history that will aid materially 
in making the diagnosis. If it is a sequence of gonorrhoea 
there will have been an attack of acute vaginitis with its 



METRITIS. 207 

symptoms. Painful micturition some time in the past is 
usually significant, especially if it was accompanied by pro- 
fuse and thick yellowish leucorrhcea with burning sensations 
in the vagina. This may have been a year or more back, 
and it is significant to note if it began a short time after 
marriage. These cases are gonorrhoea^ with rare exceptions. 
This history is more frequent among dispensary patients 
than in private practice. 

The puerperal cases will likewise give a history that is 
plain. Careful questioning will elicit an account of an abor- 
tion or delivery occurring at or immediately before the onset 
of the symptoms. In these cases there is a period of a few 
weeks or months of almost constant flooding. The amount 
varies from loss of some blood each day to a number of ir- 
regular flo wings either at the time of the regular period or 
irregularly. In the case of daily flowing cancer may be the 
cause. But the flowing from cancer begins with a slight 
" show" as a rule, and gradually increases in amount. That 
from puerperal metritis is of sudden onset or immediately 
follows labor. The flowing from fibroma also lacks the 
puerperal history, so that confusion is not common. It is 
well to bear in mind that the abortion may have been so 
early that its significance was not appreciated by the patient. 
She may have been nursing and had the flow, mistaking it 
for a return of the normal menses, or she may have been 
without her menses for only a few days over time, and will 
consequently say she never had an abortion when asked. 

Metritis may be classified as hemorrhagic and catarrhal, 
the former being usually of puerperal origin and the latter 
of non-puerperal origin. The larger part of the catarrhal 



208 MODERN GYNECOLOGY. 

cases may be traced to gonorrheal infection for their incep- 
tion, the remainder being due to hygienic errors and causes 
producing continuous pelvic congestion. The forms are dis- 
tinguished by the nature of the discharges. 

These cases of metritis are all chronic ; an acute form may 
be rarely met with, but it requires only the usual treatment 
that acute inflammation occurring elsewhere should receive. 
There should be rest in bed and antiphlogistic treatment 
until the acute symptoms subside. Douches of very hot water 
will aid in allaying the congestion, and should be used until 
the acute symptoms subside enough to allow a careful exam- 
ination to be made and the application of such local treat- 
ment as may be indicated. 

The Uterine Syndroma. — The rational symptoms of me- 
tritis are taken by Pozzi as the type of ''uterine syndroma." 
They are "pain, leucorrhcea, dysmenorrhcea, metrorrhagia, 
symptoms from neighboring organs (bladder, rectum), and 
symptoms from distant organs (digestive canal, nerves, etc.)." 
This term ' : uterine syndroma " may be used to signify the 
above symptoms occasionally to avoid repetition. They may 
all be present in metritis, but a general description of them 
will follow and not be repeated. 

Pain may be complained of either in the hypogastrium, in 
either iliac region (the left more frequently than the right), 
in the lumbar region of the back, or low down in the pelvis. 
Some women claim to be able to locate a pain in the uterus 
itself. The intensity of the pain varies from a dull heavy 
ache which is constant, to sharp, lancinating pains which are 
usually intermittent but piercing. 

The leucorrlioea of metritis also varies with its cause. That 



METRITIS. 209 

from gonorrhoea is more frequently yellowish or greenish in 
tinge, and is generally thicker in consistency. That from 
puerperal metritis is more apt to be tinged with blood. If 
the inflammation is only in the cervix the leucorrhcea may be 
clear and viscid. It may also be thin and passed in gushes, 
there being none in the intervals. 

In inquiring about the presence of leucorrhcea it must be 
borne in mind that women differ widely in what they consider 
an amount worth mentioning. Many women think a certain 
amount of discharge is normal and will deny the presence of 
any "whites," as they call it. Others again are so fastidious 
that the least amount of moisture is cause for complaint and 
leads them to seek the advice of a physician. It is well in 
all cases for the physician to ascertain for himself the amount 
and character of the flow when the other symptoms indicate 
its possible presence. Careful questioning as to the amount 
is always needed, answers as to its presence or absence being 
unreliable. 

Dysmenorrhea is not a constant symptom in metritis, and 
when present is usually due to some mechanical obstruction 
to the flow. 

Menorrhagia and Metrorrhagia. — Excessive amount of the 
flow is due to congestion of the uterus or to impaired condi- 
tion of the endometrium. When it occurs at the normal 
period it is called menorrhagia ; when the loss of blood is 
at other times it is called metrorrhagia. The cause of the 
hemorrhage may be puerperal metritis, fibroma, or carcinoma, 
and it is sometimes found in cases of anaemia. In anaemic 
cases from wasting diseases or chlorosis, amenorrhcea is 
more frequent. This may also occur in a later stage of me- 



210 MODERN GYNECOLOGY. 

tritis, when the patient has been depleted by suffering or 
loss of blood, or where the growth of fibrous tissue in the 
parenchyma of the uterus has compressed the blood-vessels, 
causing a local anaemia. 

Sterility is a symptom of metritis, the inflamed endome- 
trium being unfavorable to retention of the ovum, even if 
it becomes impregnated before expulsion from the uterine 
cavity. When pregnancy does occur it usually terminates 
in abortion at or before the third month. 

The Madder symptoms, painful and frequent micturition, 
are frequent but not constant. There is usually constipation, 
which is often accompanied by frequent, ineffectual desire to 
defecate. There may be vesical or rectal tenesmus. These 
rectal and bladder symptoms may be due to the general pelvic 
congestion in which these organs participate, or they may 
be due to interference caused by pressure of enlarged or dis- 
placed genital organs. 

Alimentary Disturbances. — The effects of uterine disease on 
the functions of digestion are pronounced. The most common 
results are loss of appetite, nausea, and flatulence. The latter 
is often the symptom for the relief of which the patient seeks 
advice. Dilatation of the stomach has been found with 
uterine disease, probably more as a coincidence than as a 
consequence. There may be vomiting. These digestive 
symptoms are reflex, as are the so-called "uterine cough," 
headaches, and neuralgiaa. They are very annoying to the 
patient and may lead to errors of diagnosis. There is usually 
no lesion except the uterine condition, and. the symptoms 
disappear with its cure. 

Uterine Reflexes. — Some characteristics of these uterine 



METRITIS. 211 

reflexes are worth mentioning here. The headaches are 
unique, both as to situation and character. The most com- 
mon type is a dull pain in the top of the head, which is 
described as pressing on the brain. If the area is extended 
it is in the direction of the back of the neck, and it may 
extend down into the spinal column, but this is rare. 

The uterine cough is usually dry and hacking, the sound 
being of such a nature as to alarm the friends. The effort 
of coughing usually occurs from two to five times in suc- 
cession. There is no lung or throat involvement. 

Impairment of voice is met with, resulting from disease in 
the pelvis. By some authorities this is attributed to ovarian 
disease, by others to disease located in the uterus. One au- 
thority claims to be able to tell when a singer is menstruating 
by the impaired tones of the voice. 

Spasm of the larynx has occurred from applications made 
to the uterus. Many of my patients claim they can taste the 
creosote the moment the applicator passes the internal os 
when intra-uterine applications are made. This symptom 
has also been noted in the experience of a number of my 
colleagues. 

Digital examination gives the evidence on which the diag- 
nosis is established. The condition of the cervix is noted. 
If there is laceration depressions are felt in the rounded 
end, depending in number and depth upon the kind of tear. 
There may be only one shallow break in the contour of the 
ring surrounding the external os, or the depression may ex- 
tend up to the point where the vaginal mucous membrane 
passes from the cervisrto form the vault of the vagina. The 
edges of the laceration may be close together or widely sepa- 



212 MODERN GYNECOLOGY. 

rated, or the parts may be so torn as to divide the cervix 
into two parts, the tear having been bilateral. Laceration 
may be found with any of the other conditions occurring 
with cervical metritis. 

Erosion can usually be detected by the touch, the differ- 
ence in the mucous membrane being appreciated by the 
examining finger. The view through the speculum corrob- 
orates its presence. 

The consistency of the whole uterus is noted, as is its size. 
In metritis there is always enlargement, the increase in size 
being most in the part most involved. This is detected 
among the first things. The cervix is harder in hypertrophy, 
especially when fibrous formation has begun. If cysts are 
present they feel like small points that are raised and harder 
than the surrounding parts. Eversion is seen at once and 
suspected from the impression given the sense of touch. At 
times the external os is slightly enlarged, admitting the tip 
of the finger j its contour is unbroken but presents a hard, 
unyielding ring to the touch. This is a common condition 
when metritis exists with some hypertrophy of the cervix. 
There may be stenosis of the internal os with such a condi- 
tion, and an enlarged uterus. 

The view of the cervix as seen through the speculum is 
important. Lacerations are evidenced by gaping of the torn 
parts, erosion by their darker color; eversions are also 
darker, but are usually raised above the adjacent tissues. 
The size of the cervix is distinguished, and cysts, if present, 
are seen scattered about over its surface. The quantity and 
kind of the discharge from the cervix is important. There 
may be almost none, but at times a translucent ropy plug is 



METRITIS. 213 

seen, which is so adherent that it is difficult to remove. The 
size and condition of this mucous plug' in the cervix has an 
important bearing on the treatment. 

The Treatment of metritis varies with the cause and the 
part most involved, and also with the stage of the disease. 
When treatment is begun early the chances of recovery are 
good but gradually diminish as the disease progresses. When 
sclerosis results from excessive production of connective tis- 
sue due to the excessive congestion, the uterus becomes very 
hard, the body being elongated while the cervix is short. 
This condition causes local anaemia and resulting amenor- 
rhcea, and is said to be incurable by Noeggerath, who de- 
scribes it, calling it " chronic metritis." It really is a late 
stage of chronic metritis, and is seldom seen in cases that 
can have early treatment, because it is avoided. Electricity 
may be tried in cases seen too late for cure by the usual 
methods. 

The treatment of metritis involving the body of the uterus 
more than the cervix must take the condition of the append- 
ages and pelvic peritoneum into consideration. If these 
organs are involved much care must be exercised, though 
some authorities advise active interference even when they 
are in a state of active inflammation. When there is active 
sepsis with fever, and symptoms of poisoning of the general 
system indicating that placental or other abnormal tissue is 
within the uterine cavity, its removal must be the first con- 
sideration. The removal of all the septic material is best 
done under ether. The. dull wire curette is usually sufficient, 
though adherent tissues may call for the sharp curette for 
their removal. In curettement for the removal of such 



214 MODERN GYNECOLOGY. 

foreign bodies the entire endometrium must be passed over. 
There may be very small particles adherent to it, and if all 
parts are not scraped some may be missed. The removal of 
all granulations is essential, as very small points of granular 
tissue may remain to keep up the infection. The points of 
the uterus around the entrance of the Fallopian tubes should 
be gone over several times. These openings may be closed, 
and a thorough curetting may remove the obstruction and 
allow the tubes to drain themselves. It is of course neces- 
sary to dilate the cervix, if small, and provide for drainage 
of the uterus through it after curettement. 

Unless the urgency of continued infection is present the 
palliative treatment is best to use while the inflammation in 
and around the appendages is active. This is best done by 
applications made to the vaginal roof. The mucous mem- 
brane surrounding the cervix is painted with tincture of 
iodine, or tincture of iodine with beechwood creosote, equal 
parts of each, or if much congestion is present the pure 
Monsel's solution may be used. If there is erosion at the 
cervix the iodine and creosote will heal it over at the same 
time. After the active inflammation in the appendages has 
been allowed to subside, a curettement can be done, or the 
metritis treated in the usual way by intra-uterine applica- 
tions. Lacerations with eroded edges are healed by the tinct- 
ure of iodine and creosote. Hard cicatricial masses from 
laceration are absorbed by the applications of iron. Since 
these masses are a cause of many of the nerve symptoms 
that accompany uterine disease this absorbent action of 
the liquor ferri subsulphatis is productive of much benefit. 
Lacerations of considerable depth will heal under this treat- 



METRITIS. 21.3 

ment when persisted in for sufficient time, and the reflex 
symptoms will all disappear. This ability to heal deep cer- 
vical lacerations without operation is a great boon to many 
women who dread operations ; they will cheerfully submit 
to be treated for many months rather than take ether. Per- 
sistent applications of the Monsel's solution in full strength 
will eventually restore any but the very worst form of lacer- 
ated cervix to a condition that will produce no symptoms, 
and she will be in safer condition to go through a new par- 
turition than if an operation had been done. 

Most cases of metritis should have a tampon applied after 
the other medicines. If there is much congestion it should 
be thoroughly saturated with glycerine and should fit firmly 
enough to exert considerable pressure. The tampon also 
absorbs the drugs applied, and by remaining in contact with 
the mucous membrane gives a prolonged application. It 
should be worn for from twelve to twenty-four hours, but 
must always be removed when pain is produced. When 
no congestion exists the glycerine should be omitted. 

If cervical metritis is also present some application should 
be made to the endocervical mucous membrane. The iodine 
and creosote acts very well at times. If the mucous dip- 
charge is very tenacious equal parts of pure carbolic acid 
and glycerine will remove it. It is necessary to remove this 
plug of mucus before the remedies can reach the underlying 
mucous membrane. 

When there is much congestion of the cervix the blood 
should be removed by puncture with a lancet and allowed 
to bleed for a time. A leech may be applied to the cervix 
to deplete it if the puncture is not sufficient. The artificial 



216 MODERN GYNECOLOGY. 

leech may be used for this purpose. The glycerine is indi- 
cated in these cases. 

After the inflammation in and around the appendages has 
subsided treatment can be directed to the endometrium. A 
radical removal of all septic material from the uterine cavity 
is indicated, after which the whole parturient canal must 
be kept in a condition of the most thorough asepsis. For 
the removal of detritus the dull wire curette is the safest 
instrument (see Fig. 34). After the cavity is thoroughly 
cleansed with this, a strong antiseptic should be applied. 
The best is carbolic acid, either pure or a fifty-per-cent 
solution in glycerine. The application must reach all the 
mucous membrane within the uterus from fundus to cervix. 
Care should be taken not to let any of the acid remain in 
the canal, and also not to allow it to come in contact with 
the vaginal mucous membrane or to run out over the exter- 
nal parts. 

The cervix must be kept open either as a result of thor- 
ough dilatation, or by gauze or an Outerbridge drain. The 
gauze is used when the dressings are to be changed fre- 
quently and new applications made. The interior of the 
uterus should be made as dry as possible first. The gauze 
is previously made aseptic by baking, and is in long strips 
about an inch in width. This is taken near the end with 
a clean pair of forceps and carried to the fundus. Two or 
three loops thus carried the length of the uterus will do for 
drainage, but if there is tendency to discharge from the uter- 
ine mucous membrane pressure must be made by filling the 
cavity with gauze. It is not wise to pack too tightly or leave 
the packing in very long if there is purulent discharges from 



METRITIS. 



217 



the tubes, for the pus may be dammed back and forced out 
their fimbriated euds into the abdominal cavity. 

Where there is tubal discharge and no need of intra- uter- 
ine pressure a drain to keep the cervix open is best. The 




gold wire drain invented by Dr. 
Outerbridge answers this pur- 
pose well. Figure 50 shows the 
drain in position and the ease 
with which an exit for the con- 
tents of the tubes is afforded by 
it. The vagina and vulva must 
be kept clean by^ frequent douch- 
ing and bathing with hot water 
and mild antiseptic solutions. 
Mild solutions of bichloride of 
mercury are best for bathing the 
vulva, plain hot water being usu- 



218 MODERN GYNECOLOGY. 

ally sufficient for the vagina, although borax, sodium chloride, 
or salol may be used, or the bichloride or carbolic acid solu- 
tions may be indicated if the discharges are very offensive. 
In using these stronger solutions the plain hot water is first 
used, and only the last pint or two of the douche contains 
the antiseptic. 

Intro-uterine Applications. — Milder cases of metritis do not 
need the curette but must have intra-uterine applications. 
These are made in various ways. The uterine applicator is 
probably the most used for this purpose. This is a long, 
flat piece of flexible metal with a blunt point (see Fig. 51). 
In using, it should first be moistened and then tightly 
wrapped with a thin layer of cotton from the point far 
enough back to allow at least an inch of the wrapped surface 
to remain outside of the external os when the point is at the 
fundus. For manner of wrapping see Figure 52. The point 
should be well protected with the cotton. Figure 53 repre- 
sents the applicator wrapped for using. This cotton is satu- 
rated with the medicament after the applicator has been bent 
to the curve of the uterine canal; the instrument is then 
introduced through the cervix and carried gently to the fun- 
dus. It is well to let the applicator remain in the uterus for 
a few seconds before removal. If any obstacle is felt to its 
introduction a tenaculum can be hooked into the cervix and 
by gentle traction the canal straightened somewhat to permit 
an easier passage j this will also prevent the cervix from 
dimpling with the point of the instrument so as to prevent 
its free entrance. Very little force can safely be used either 
on the tenaculum or the applicator. 

The remedies used for intra-uterine applications made in 



METRITIS. 



219 





Uterine Applicators. 



220 MODERN GYNECOLOGY. 

this maimer are pure tincture of iodine, tincture of iodine 
and creosote, or carbolic acid and glycerine, equal parts of 
each, and MonsePs solution. 

Applications to the endometrium may be made every three 
days if they do not set up too much reaction. In some cases 
they can be made only once in ten days or every two weeks, 
the treatment at the intervening visits being limited to ap- 
plications to the vagina. 

Injections of various remedies directly into the uterine cav- 
ity are recommended by some gynecologists. A more copious 
application can undoubtedly be secured in this way, but it is 
not devoid of risk. Pletzer records a case of death following 
intra-uterine injection of the official (German) solution of 
ferric chloride for hemorrhage, in which the autopsy showed 
the cause of death to be heart thrombus. A vein contin- 
uously filled with clotted blood was traced from the uterine 
mucous membrane to the internal iliac vein. 

Substances used as intra-uterine caustics are pure tincture 
of iodine or Churchill's tincture, strong solutions of zinc sul- 
phate, nitrate of silver, peroxide of hydrogen, etc. 

Arnaud applies a pencil of pure copper sulphate, which is 
left within the uterus. Only one application is made, and 
cures are claimed in from four to twenty-five days. I have 
seen no record of this treatment being tried in America. 
Antiseptic douches to the vagina are used for two days, and 
full doses of bromide given for one day before applying the 
pencils. 

Rheinstader of Cologne first used zinc chloride for intra- 
uterine applications. This he dissolves in an equal quantity 
of water, and injects the solution into the uterus hot more 



METRITIS. 221 

frequently than every five days. There will be a copious 
purulent discharge for two days after each application. The 
application is followed by the introduction of a glycerine- 
saturated tampon, to be worn twelve hours. 

Euphorin in the form of a powder has been blown into the 
uterine cavity or injected in the form of a solution contain- 
ing one part of euphorin to three of alcohol. This is the 
method recommended by Bergeric. 

Electricity has many advocates who extol its virtues as a 
caustic in metritis. Its great objection is the difficulty in 
cauterizing the entire surface of the endometrium with it. 
The granulations can be removed much more certainly with 
the curette or reached more thoroughly with liquid caustics 
introduced with an applicator. The merits of electricity will 
receive more attention in the pages devoted to the treatment 
of fibroma. 

Treatment of Cervical Metritis. — Some points in treatment 
of metritis located chiefly in the cervix have already been 
touched upon. The applications of iodine and creosote, of 
Monsel's solution of iron, and of glycerine-saturated tampons 
have already been mentioned and their uses indicated. It is 
only necessary to say of them that much patience is called 
for on the part of patient and physician in order to secure 
their best results. It may be necessary to keep up the treat- 
ment for many weeks, and it is always advisable to make 
several applications at intervals of two or three weeks after 
the metritis is' seemingly cured. This will enable the physi- 
cian to guard his patient against relapses, and she will also 
be less liable to comnirLhygienic errors when she knows she 
must make a few more calls on her physician. 



222 MODERN GYNECOLOGY. 

Conditions of the cervix requiring special mention as to 
treatment are hypertrophy, cystic formation, and extensive 
laceration. If the hypertrophy is extensive and fails to yield 
to the applications above mentioned, it may be necessary to 
amputate. This is usually done by removing a cone-shaped 
piece, with the external os in the center of its base and its 
apex as near to the internal os as may be indicated. The 
resulting opening is then closed by sutures making one line, 
the canal being kept open by a metal drain or glass stem. 

If cysts are present there is usually hypertrophy as well. 
They must all be carefully dissected out, as a part of one will 
cause recurrence if left. The only cure for these is their 
removal. 

Hard nodular masses are sometimes found in the cervix 
with metritis. They can at times be absorbed by local appli- 
cation of Monsel's solution, but they, if they prove refract- 
ory to this treatment, must be removed by the knife. The 
actual cautery has been used for removal of cysts and nod- 
ules, but the knife is more easily controlled and therefore 
more satisfactory. 

Lacerations of considerable depth and extent can be made 
to close completely by local remedies applied directly to them. 
The nitrate of silver in the form of lunar caustic has long 
been used for this purpose, but since its use began the pure 
liquor ferri subsulphatis has found even better favor, and its 
results are at times surprising. When the tear is extensive 
and the resulting metritis is intractable, or where the curette 
is indicated for the endometrium, it is best to repair the cer- 
vix by operation during the etherization. The most impor- 
tant points about this operation are perfect asepsis, removal 



METRITIS. 223 

of all hypertrophic tissues, perfect apposition of the denuded 
surfaces with as few stitches as possible, provision to keep 
the cervical canal from closing, and uninterrupted drainage 
of the uterus during the healing period. 

The importance of hot douches must not be overlooked in 
all cases of metritis. They should be persisted in no matter 
what the plan of treatment employed. They should be hot 
(from 110° to 118° by Fahrenheit's thermometer), copious 
(from one to two gallons), and should always be taken with 
the patient in the dorsal recumbent position. The impor- 
tance of this position for the vaginal douche cannot be too 
forcibly impressed. Patients will invariably take it squatting 
over a vessel unless taught otherwise. It is safest to inquire 
in all cases and to impress upon her the necessity of lying 
on her back to take her douche. The frequency of the douche 
varies from every few hours to twice daily. If there is tend- 
ency to hemorrhage or acute inflammation it should be used 
every two or three hours, while in cases of simple metritis 
twice each day is sufficient. Its only contra-indication is 
ovarian inflammation, which requires that the temperature 
be lowered. 

In metritis, as in ante-displacements of the uterus, an ab- 
dominal band will often give the patient much comfort j this 
is especially true of stout women. The band should be broad, 
and so worn as to raise the lower abdomen. It must not be 
worn as a belt, which, like the corset, forces the contents of 
the cavity downward and causes bulging and laxness of the 
walls immediately above the pubes. This is precisely the 
place where support and pressure are needed ; perineal bands 
may be required to keep the binder down in place. 



224 MODERN GYNECOLOGY. 

Patients with metritis must not dance or take long walks, 
and they should not use their feet as motive power for ma- 
chinery, neither should they stand for long periods nor sit 
for a long time iu one position. They should have light 
exercise in the open air and treatment for the general health. 
It will be wise to have them lie down more or less each day, 
and in severe cases the recumbent position must be main- 
tained until improvement sets in. 

The Medicinal Treatment of metritis varies with the gen- 
eral health of the patient. Stout, plethoric women require 
remedies to stimulate the liver and relieve constipation. 
This is frequently attained by the following prescription : 

$ 

Sodii. bicarbon 5 ij 

Pulv. rhei gr. xlv 

Pulv. ipecac gr. vj 

AquaB menth. pip q. s. ad § vj 

M. Sig. 3 ij before meals in a wine-glass of water. 

If much flatulence is present with large tympanitic abdo- 
men, ten or fifteen minims of tincture of mix vomica should 
be added for each dose in the above prescription. 

The fluid extract of cascara segrada can be used for the 
constipation if an additional purgative is needed. It is best 
given in doses of from twenty drops to a teaspoonful in 
water before retiring. Women of this type will need the 
above prescription for many months. They are frequently 
above forty years of age and have neglected the condition of 
their alimentary canal for years, and much time is required 
to get these organs to perform their functions without assist- 
ance ; they have the constipation habit, and must supplant 



METRITIS. 225 

it with the habit of regular daily evacuations. A most im- 
portant factor in the treatment is to get them to realize the 
importance of a daily defecation. 

Women with metritis of gonorrhoea! origin, and frequently 
with tubal involvement from the same cause, will require 
different remedies for their general health, if there is con- 
stipation with sluggish liver and large, flabby abdomen, the 
rhubarb mixture and cascara will be indicated. But these 
patients are usually more or less anaemic. They are fre- 
quently much helped by taking the " four chlorides/ 7 the best 
formula for which is probably the following : 

Hydrarg. chloric!, corros gr. j 

Liquor, arsenic, chlor. 
Tr. ferri. chlor. 

Ac. hydrochlor. dil aa 3 iv 

Syr. simplex § iij 

Aqua q. s. ad § vj 

M. Sig. 5 ij after meals. 

This must be well diluted in water. It can be taken for 
six weeks, when its use must be suspended for a month, and 
then it can be resumed for the same period as before. This 
plan may be continued for about six months if benefit result 
from its use. 

Metritis occurring in unmarried women or in wojnen who 
have not borne children is often accompanied by anaemia, 
either as a result of overwork and faulty assimilation of food, 
or due -to the depletion -from loss of blood from the uterus. 
The alimentation must first be corrected in all cases, and 
after the tendency to hemorrhage has been controlled large 



226 MODERN GYNECOLOGY. 

doses of iron must be given in the manner indicated in the 
pages devoted to anaemia. Where the uterus is large and 
tender, with tendency to menorrhagia or metrorrhagia, it is 
well to stimulate its muscular fibers to contract by internal 
remedies. The fluid extract of the cornuta secale with tinct- 
ure of mix vomica acts well for this purpose. Twenty 
minims of the ergot with ten minims of the mix vomica 
should be taken in water before each meal. The fluid ex- 
tract of hydrastis canadensis may be added with profit when 
the hemorrhage does not yield to the above treatment, or it 
may be substituted for the ergot in case that drug should 
disagree with the stomach. 

Extr. ergot, fl. 

Extr. hydrast. fl aa § j 

Tine, nucis vomic § ss 

Tine, gentian, comp q. s. ad § vj 

M. Sig. 3 j before each meal, in water. 

The use of these remedies for metritis without local treat- 
ment is not in accordance with modern methods of treat- 
ment. Some effort must be made to remove the cause, the 
internal remedies being simply adjuvents to the local treat- 
ment which has been already outlined. The treatment of 
retained placenta with or without metritis- has received atten- 
tion under the head of uterine hemorrhage. 



CHAPTER XI. 

UTERINE DISPLACEMENTS. 

The normally situated uterus rests in the pelvis in a 
position corresponding to the curvilinear axis of the pelvic 
canal. It has a slight curve forward, "the normal ante- 
flexion " of the litems. This anterior curve is obliterated by 
the pressure of a full bladder, and is exaggerated when the 
bladder is empty. The condition of the rectum also influ- 
ences this curve, but in a minor degree, pressing the fundus 
more anterior when full, and allowing it more room in the 
hollow of the sacrum when empty. These movements indi- 
cate a certain amount of variation in the curve that is not 
pathological. The relative position of the uterus and other 
pelvic organs is shown in Figure 54. 

The Supports of the Uterus. — The uterus stands upward 
from the pelvic floor, and is held in position by ligaments. 
The strongest of these are the utero-sacral ligaments, which 
are attached to the sacrum at their posterior ends. They 
are strong and inelastic. Their uterine attachment is at 
either side, on a level with or slightly below the internal os; 
This causes the thinnest part of the uterus to be the fixed 
point when these ligaments are tense ; the uterus thus rests 
as a cone on its apex, making displacements easy. 

The other supports are the broad ligaments attached to 
the sides of the uterine body and reaching to the sides of the 

227 



228 



MODERN GYNECOLOGY. 



bony pelvis, the round ligaments, also at the sides, and the 
fold of perineum connecting the bladder with the uterus. 




Fig. 54. Correct Position of the Pelvic Organs. (C. H. B.) 



All the ligamentous supports of the uterus are so attached 
as to allow a considerable amount of motion in all directions. 
It is only when its position becomes permanently changed 
that the condition can be called pathological. These mal- 
positions are usually the result of some diseased condition 
of the uterus or its surroundings. 

Deviations from the normal are classed as " displacements 
in the vertical planes " and " displacements in the horizontal 
planes." The former term includes "versions" and "flex- 
ions/' and the latter " elevations, prolapses, and inversion " 



UTERINE DISPLACEMENTS. 



229 



(Pozzi). There is also a condition in which the uterus as a 
whole is moved backward or forward — usually backward 
into the hollow of the sacrum. These are called ante- and 
retro-positions, and are not of much importance of them- 
selves, being complications of other diseases. 

Anteversion. — The attachment of the utero-sacral liga- 
ments at the narrowest point of the uterus gives it a position 
as if swung upon pivots, and the fundus can swing back and 
forth and to the sides to a limited extent under normal con- 
ditions. The cervix in the vagina always swings in the op- 
posite direction, its movements being less in extent because 
its distance from the fixed point is less. 




Fig. 55. Anteversion. 

When anteversion occurs from any cause the fundus passes 
forward and downward farther than usual, and remains in 
this position. The normal anterior curvature is obliterated, 
and the uterus lies straight and flat, in contact with the an- 
terior vaginal wall and the bladder, the fundus being behind 
the pubes. The cervix at the same time passes upward and 



230- MODERN GYNECOLOGY. 

backward, occupying a position high up in the posterior cul- 
de sac of the vagina, its opening pointing backward (Fig. 55). 

The Causes of anteversion are usually found in the uterus 
or its appendages. Subinvolution is a common cause j the 
uterus fails to resume its normal size and tone after parturi- 
tion, and falls out pf place because of its weight. Metritis 
from non-puerperal cause, relaxation of the ligamentous sup- 
ports of the uterus, prolapse of the appendages, and peri- 
salpingitis are frequent etiological factors in causing ante- 
version. 

The Symptoms are variable, anteversion being found at 
times without any symptoms being complained of. There 
is usually found, however, the usual symptoms of pelvic dis- 
ease, as pains in the "pelvis, tenesmus, etc. There may be 
leucorrhcea, dysmenorrhea, menorrhagia, or metrorrhagia, 
but these can usually be accounted for as due to associated 
metritis, salpingitis, etc. The most frequent symptoms are 
bladder irritability and frequent micturition. There will at 
times be nervous symptoms associated with anteversion, but 
these are more frequently found with anteflexion. 

Examination. — The examining finger with difficulty finds 
the cervix far back in the posterior pocket of the vagina, 
and can follow the outline of the uterus anteriorly along the 
anterior wall of the vagina to the fundus. Rectal examina- 
tion will show the absence of the fundus in its normal posi- 
tion, and if any doubt remains it may be removed by a 
bimanual examination ; but this is seldom needed. The 
passage of a sound is often difficult and at times impossible 
in these cases, and is not devoid of danger. When at- 
tempted, it will iisually be found easier to accomplish if the 



UTERINE DISPLACEMENTS. 231 

cervix be drawn downward and forward with a tenaculum. 
If adhesions have fastened the fundus to the anterior peri- 
toneal depression, it will usually be impossible to get the 
sound passed, and too much effort to do so may set up a 
pelvic -peritonitis with all its dangers and embarrassments. 
It is best not to attempt to pass a sound in these cases. 

The Treatment must take into account the associated con- 
ditions that are found. If there is metritis it must be 
treated j if prolapse of the adnexa, effort must be directed 
to them j if inflammation around the tubes, it must be ab- 
sorbed before any special efforts are directed to the mal-posi- 
tion itself. Where adhesions exist remedies should be ap- 
plied to the vaginal vault for the purpose of dissolving them, 
such as tincture of iodine, MonsePs solution, glycerine, or 
electricity. At the same time efforts at gradual reposition 
can be made. These should be sufficient to stretch the adhe- 
sions slightly but not enough to set up any inflammation. 

When there are no adhesions, or after they have been 
absorbed, and the metritis, etc., cured, the uterus can be re- 
placed and held in place in various ways. The least danger- 
ous is by tampons, either of cotton or absorbent wool. These 
must be placed with a proper understanding of the mechan- 
ics of the condition to be remedied, or they may do more 
harm than good. The first tampon must be placed behind 
the cervix, high up in the posterior cul-de-sac of the vagina, 
making it impossible for the cervix to go back into its ab- 
normal position. This will hold the fundus, the other end 
of the lever, in its proper place. Other tampons should be 
placed in the vagina in such positions as to fill it well and at 
the same time hold the first one in position. These can be 



23: 



MODERN GYNECOLOGY. 



worn for from twenty-four to thirty hours, when they should 
be removed, and a thorough douche of hot water should be 
taken. This douche should be used two or three times daily 
until the next treatment, which should be in about three 
days. This method by tampons is the safest and most satis- 
factory, and it can be done at the same time that treatment 
is being given for any complications that may exist. 

Pozzi recommends a soft-rubber ring pessary (Mayer's) to 
fill the vagina and hold it tense, and an abdominal pad ap- 
plied just above the pubes to hold the fundus back in place. 
Anteversion pessaries have been invented by Graily Hewitt, 
Thomas, and Gralabin, but none of them are completely satis- 





Fig. 56. Thomas 1 Anteversion 
Pessary. 



Fig. 57. Thomas 1 Anteversion 
Pessary in Position. 



factory nor free from danger. In using pessaries the greatest 
care must be exercised in their selection and in fitting them, 
and they must be examined frequently to see that they are in 
proper position and are not causing erosion somewhere in 
the vagina. They need to be removed at frequent intervals 
and thoroughly cleansed. The soft -rubber ring pessary does 
not interfere with the woman's marital relations to the same 



UTERINE DISPLACEMENTS. 233 

•extent the hard rubber instruments do. Fecundation is 
possible with either. The hard-rubber instrument can be 
worn for a longer time without removal for cleansing*. If 
worn too long a pessary may become imbedded in the tissues 
and cause much injury. This is more likely to occur in 
cases that are lost sight of for a time. They feel relieved 
from the symptoms and go on imagining everything is all 
right, until by and by they suffer more than ever before and 
apply for advice. 

Thomas' anteflexion pessary (Fig. 56) is the best one in 
use. The uterus is first restored to its normal position, and 




Fig. 58. Other Forms of Anteversion Pessaries. 

then the pessary is introduced and placed so that the correct 
position is maintained (Fig. 57). Other forms of antever- 
sion pessaries invented by Thomas are shown in Figure 58. 

Anteflexion. — A few words on the shape and development 
of the uterus are needed for a correct understanding of the 
causes and treatment of anteflexion. 

Causes of Congenital Anteflexion. — The normal uterus has 
been compared to a pear, the small end being downward. 
This resemblance is greater if the stem of the pear be drawn 
out, leaving a canal with an unbroken margin opening into 
the small end. As all have seen pears deformed by a "blight" 
or " knot " on one side, so the uterus may be deformed by a 



234 MODERN GYNECOLOGY. 

failure in its development on one side. This is due to f aulty 
nutrition at this point, and will cause the organ to bend 
toward that side. As these faults usually occur in the ante- 
rior uterine wall they usually result in anteflexions. This 
is the usual cause of " congenital " anteflexion. This want 
of development may occur at any time before puberty, but it 
more frequently occurs at or immediately before that time. 

The uterus grows little from birth to puberty, being be- 
fore the establishment of its physiological function an "in- 
fantile uterus.' 7 At this time it increases in size to that of 
an adult uterus in a very short time. This increase is found 
in both its corporeal and cervical portions. The body be- 
comes longer and larger in circumference, and its cavity 
increases in length ; it also rises higher in the pelvis, the 
point corresponding to the internal os being that part re- 
maining nearest in a fixed position. Meanwhile the cervical 
portion has also been growing • prior to this period it was 
small, conical, and very little depressed below the vaginal 
roof ; but now it becomes rounder in outline, and grows 
longer by pressing downward, carrying the vaginal mucous 
membrane with it. The opening to its canal becomes larger, 
and the canal itself is longer. The corrugations in the mu- 
cous membrane within the cervix deepen, forming the arbor 
vitce uterinus. These are the conditions when the develop- 
ment is normal, but any cause preventing a free circulation 
of blood to nourish the uterine wall will result in impaired 
development of that side, while the rest of the organ grows 
to its normal size ; the result is a congenital anteflexion. A 
congenital retroflexion might occur in the same way, but it 
is rarely met with. 



UTERINE DISPLACEMENTS. 235 

Causes of Acquired Anteflexion. — Other causes of anteflex- 
ion are frequent in parous women, the congenital variety 
being more frequently found in nullipara. Among the causes 
of acquired anteflexion subinvolution ranks first. This is 
often the result of an abortion at which there was slight 
sepsis causing a metritis, thus preventing the return of the 
uterus to its normal size. Want of involution of the pos- 
terior wall may be due to the attachment of a piece of retained 
placenta at that point, the involution of the rest of the organ 
going on in a normal manner and producing anteflexion. 
The other great causes of anteflexion are found in the sequela? 
of gonorrhoea, — as metritis, salpingitis, and pelvic exudations 
forming adhesions around the uterus. Occasional causes 
are mollites uteri ; falls, especially if she alights on the but- 
tocks; sudden strain, as from lifting; catching cold, pro- 
ducing uterine congestion, usually the result of indiscretions 
at the time of menstruation ; tumors of the body of the ute- 
rus or behind it pressing it forward. 

The Symptoms of congenital anteflexion form a marked 
contrast to those from the acquired variety. The clinical 
picture is entirely different. Women whose uteri are abnor- 
mally bent forward from a time prior to the inception of 
uterine activity are usually young when they come to the 
physician's hands for aid. They are anaemic, and usually 
poorly nourished, though they may incline to stoutness if 
chlorotic. There is often scanty menstrual flow of a light 
color, and it may be absent entirely ; in some cases there is 
an extensive flow due to the thinness of the blood. Dys- 
menorrhcea is common, ^and lasts until the flow is fully estab- 
lished ; this is generally with the passage of a clot, and may 



236 MODERN GYNECOLOGY. 

be accompanied by some febrile action. The pain is often 
so intense for a few hours as to cause her to go to bed, where 
she lies in a doubled-up position until the clot is passed. 
She then can arise and be in comparative comfort until the 
next period comes round, whei^ she again must take her bed 
and suffer. If a number of clots are passed several parox- 
ysms of pain will be present during an interval lasting a 
day or more. There may be leucorrhcea, which can be ac- 
counted for in most cases by other causes. It is frequently 
the leucorrhcea so often found in poorly nourished young 
women. A most annoying symptom is irritability of the 
bladder, which is due to the fundus pressing upon that vis- 
cus, causing frequent micturition with all its inconveniences. 
There may be dysuria at the same time. If the patient is a 
married woman she will find herself sterile in many cases 
and will frequently develop dyspareunia. If she has not 
suffered before her marriage from " nervousness " she soon 
begins to have this most annoying of maladies as a result of 
the increased activity the marital condition induces in her 
pelvic organs. This may show itself in the form of " nerves," 
hysteria, or neuralgia, or it may produce epilepsy, all of 
which are increased at or immediately before the menstrual 
period. These neurotic symptoms are due to irritation caused 
by the presence of an unyielding point in the uterine wall. 
They are of the same nature as those produced by a cicatri- 
cial plug in the cervix, which is so frequently found in women 
who have borne children, and are from a precisely similar 
cause. When the anteflexion is associated with relaxation of 
the uterine ligaments these nervous symptoms may be, in 
part at least, due to the excessive mobility of that organ, 



UTERINE DISPLACEMENTS. 237 

Anteflexion of the acquired variety when due to the results 
of parturition or gonorrhoea is sometimes found without any 
symptoms being complained of ; but there is usually found 
to be leucorrhcea, bearing-down pains, backache, pains in the 
pelvis, and inability to retain the urine until the bladder is 
full. Dysmenorrhea and painful coition may also be present, 
and the impaired activity of the nervous system may manifest 
itself ; but some of these symptoms at least are due to other 
causes, as metritis, laceration of the cervix, or salpingitis. 

The Cause of the Dysmenorrhea is in dispute. It is thought 
by many to be due to mechanical interference with the pas- 
sage of the blood produced by the bent and usually stenosed 
canal, which causes the pain to be so intense at the begin- 
ning of the flow and less after the canal has been dilated by 
the passage of a blood clot. To this idea is opposed the fact 
that cases of anteflexion with stenosis do exist in which men- 
struation goes on for many years without any pain whatever, 
the menstrual blood seeming to be able to pass through a 
very small opening freely enough to prevent its accumula- 
tion in the uterine cavity. The f ailure of the blood to form 
a clot in these cases may account for the absence of pain. 
The view more in accordance with the knowledge of to-day 
is undoubtedly true, at least in part. It teaches that the 
undeveloped part of the anteflexed uterus is unyielding, and 
when the organ enlarges, as a result of the congested state 
present at the beginning of menstruation, this undeveloped 
part offers a resistance to this enlargement and causes pain. 
The anterior uterine wall is wanting in elasticity in all cases 
of congenital anteflexion and resists any effort to enlarge 
the uterus, producing pain. 



238 MODERN GYNECOLOGY. 

The Cause of the Sterility usually found with anteflexion 
has also been in dispute, it being maintained by some that 
it is due to the mechanical interference with the entrance of 
the semen into the uterine cavity caused by the curved and 
narrow canal ; to this is opposed the ease with which the 
spermatozoa are known to pass through a very narrow in- 
ternal os, they having been found in the tubes of women who 
had died but a few days after a coition, in whom there was 
also found an anteflexion and stenosis so narrow as to cause 
surprise that an)i:hing could get through. It has always 
seemed to me that a more probable cause of the sterility is 
the faulty position of the cervix in the vagina. This is espe- 
cially true where there is anteflexion of the neck of the ute- 
rus. The cervix is not in its usual place, well back in the 
posterior cul-de-sac of the vagina, with its opening facing 
backward ; it is now directed more or less forward, and the 
opening at least is forward in its direction. This causes the 
cervix to be in a position where it is less liable to be bathed 
in the seminal fluid, and the entrance of the spermatozoa 
into the cervical canal and thence into the uterus is less 
likely to occur. No doubt each of these conditions acts as a 
contributing cause in many cases, but it is my impression 
that the latter is a more potent factor in the production of 
the sterility. This opinion is strengthened by the fact that 
those cases of anteflexion in which the cervix occupies such 
a position that the external os is sure to be bathed in the 
spermatic fluid at the time of its discharge into the vagina 
are the cases in which sterility is least frequently found. 

Chi Examination the diagnosis is easily made out in most 
cases, but mistakes have been made by experienced examin- 



UTERINE DISPLACEMENTS. 



239 



ers. A classification of the different forms of anteflexion will 
aid in detecting this condition. The best is that of Thomas. 
He calls the three forms described " anteflexion of the body/' 
'•'anteflexion of the cervix/' and "anteflexion of both the 
body and the cervix." 

In Anteflexion of the Uterine Body the examining finger will 
nsnally detect nothing abnormal at first touch. The external 
os and cervix will be normal, and the whole vaginal portion 
of the litems is in its usual position or nearly so, the cervix 
pointing in the backward direction and being of normal size 




Anteflexion of the Uterine Body. 



and consistency. But when the finger is pressed upward 
by the side of the cervix, gently but firmly invaginating the 
vaginal mucous membrane and noting the consistency, size, 
and direction of that portion around the internal os and 
above it, it will detect a curve greater than should be, and 
in the anterior direction. Following the contour of the 



240 MODERN GYNECOLOGY. 

uterine body, the finger will be partially withdrawn as it 
approaches the fundus, the anterior wall of which is found 
resting against the upper part of the anterior vaginal wall if 
the flexion is marked and the bladder is empty (Fig. 59). If 
the finger is pressed directly in front of the cervix it enters 
an angle formed by the flexion. Hardness of the undevel- 
oped wall is also detected by touch, and is usually around 
the anterior part at the level of the inner os or just above it. 
Probably the only condition liable to be mistaken for this 
form of anteflexion is a tumor in the anterior uterine wall, 
or a tumor in the pouch between the uterus and the bladder 
and adherent to the anterior wall of the uterine body ; but 
neither of these conditions will be confusing to the examiner 
who follows carefully the method suggested above, remem- 
bering that the finger must pass to the side of the cervix and 
follow its contour upward or in whatever direction it may 
lead. This may be difficult to the beginner and the results 
obtained may at first be uncertain, but a few careful trials 
will enable any one to be positive of his ground and to safely 
and surely map out the position of the uterus almost to the 
fundus. If any condition be present making the pelvic floor 
thick and resistant, it will obscure the mapping-out pro- 
cess to an extent depending on the amount of thickening. 
In all cases where the least doubt exists the bimanual meth- 
od must be used to clear up the diagnosis. A few cases will 
be met with in which even this method will not give positive 
evidence as to the condition. If doubts exist the sound must 
be passed, thus positively deciding the position of the uterus. 
Where the sound cannot be passed, or for any reason its use 
is deemed unsafe, examination by the rectum will add much 



UTERINE DISPLACEMENTS. 241 

light to the knowledge of the condition and should be 
tried. 

Anteflexion of the Cervical Portion of the uterus is evident 
on examination, as the finger detects the abnormal position 
of the cervix at once, pointing directly forward. Care must 
be taken, as before stated, to follow up the line of the uterus, 
locating carefully the position of the fundus, as the position 
of the cervix is near enough the same in each for a marked 
retroversion to be mistaken for this misplacement, or vice 
versa. When the uterus is enlarged the bend at the internal 
os may be mistaken for the fundus ; the finger by the side of 
the cervix will detect the difference at once. 

Anteflexion of both the Body and Neck of the uterus is a 
combination of both of the above-mentioned conditions. The 
only point needing care in making a true diagnosis is that 
the examining finger be pressed up by the side of the cervix 
far enough to map out the position of the fundus correctly. 
A few points in the history of a case of this kind will be in- 
structive. This patient had been examined by two promi- 
nent physicians in a neighboring city, one of whom is a 
member of the faculty of a well-known college there, and 
had been told by both that she had retroversion. This diag- 
nosis she was more ready to accept as it confirmed a former 
one made by a physician in her native town in New England 
some years before. No treatment was made by any of these 
men for the local condition, and no sound was passed to 
verify their statement as to the position of the uterus. She 
suffered much pain, and- was in bed about two weeks at the 
time of the last examination, during which time she was seen 
by two physicians, as above mentioned. Two months later 



2-42 MODERN GYNECOLOGY. 

she came to New York, and being taken with an attack of her 
old trouble was brought to me. Her symptoms suggesting 
pelvic trouble, I suggested an examination, which was made. 
There was an anteflexion of the neck and body of the uterus 
present in a marked degree, with some sinking of the whole 
organ into the hollow of the sacrum. It was as clear a case 
as I ever saw. The only chance of mistake was in the fact 
that the uterus was somewhat enlarged, and the bend at the 
internal os gave to the finger an impression much like that 
of the fundus in retroversion. This diagnosis would be more 
readily accepted as she was a woman who had never borne 
children and her uterus might be supposed to be small. 
When the finger was pushed high up by the side of the cer- 
vix the line of the uterus could be followed the whole distance 
to the fundus, which was found in the anterior fornix, press- 
ing against the bladder. The mistake made by these men 
was easy to make. The cervix pointed anteriorly, was long, 
and the bend in Douglas' cul-de-sac felt much like the fundus 
in retroversion. My universal habit of mapping out the 
position of the uterus by keeping the examining finger at the 
side of that organ saved me from repeating the error made 
by the others. 

Exploration by the sound, and the result of treatment, 
which relieved all her uterine symptoms, verified my diag- 
nosis, which was also corroborated by a prominent specialist 
in Boston, who was called in during a sudden attack she had 
while visiting that city some months later. 

Anteflexion of both the body, and the neck is sometimes 
confused with anteflexion of the body which has become 
retroverted. The cervix points in the same direction, and 



UTERINE DISPLACEMENTS. 



243 




the first touch is the same to the examining finger. The 
position of the fundus is not the same, it being upward in a 
position almost normal. If it were in its 
normal position the condition would be 
that of an anteflexion of the neck alone. 
The distinctive point in this condition is 
the fact that the uterus as a whole has 
changed its position in the pelvis; the 
anteflexed uterus has swung backward 
on the pivotal or fixed point, causing the 
cervix to move upward and forward. 
This complication needs no further men- 
tion here, as a knowledge of the true con- 
dition will cause the proper treatment to 
be used, which is, to treat the retroversion 
as any other retroversion after the ante- 
flexion has been treated. There may be 
a prolapse of the whole uterus at the same 
time with the retroversion of the ante- 
flexed organ ; in fact, there usually is. 

Frequent mention has been made in 
the preceding pages of the use of the ute- 
rine sound. A few suggestions in regard 
to the use of this instrument are neces- 
sary. Figure 60 is Simpson's sound, one 
very commonly used. For convenience 
in measuring the length of the uterine 
canal this instrument is graduated. 
Hunter's sound (Fig. 61) is also much used ; it is a smaller 
instrument. Sounds should be made of flexible metal, in 



244 MODERN GYNECOLOGY. 

order that they can be molded to suit the direction of the 
canal. 

Passing a sound into a normal uterus is not attended with 
much difficulty. But it must be understood that it is a pro- 
ceeding not devoid of danger to the patient. I have seen 
much injury result from this seemingly simple procedure and 
several patients' lives put in jeopardy. 

Some of the contra-indications to the use of the sound are 
recent pelvic peritonitis, suspected pregnancy, or fear of 
causing hemorrhage. The best time for its use is a few days 
after the menstrual flow has ceased. 

In anteflexion the curve must be made considerably more 
than in retroflexion ; the sound being flexible, its shape is 
easily molded by the fingers to any shape desired. The in- 
strument may be passed with the patient in Sims' position or 
in the dorsal position. In Sims' position Sims' or Cleveland's 
speculum is used, while in the dorsal position a bivalve is 
necessary. It is possible to pass a sound without a specu- 
lum, but it is seldom necessary to do so. When a sound is 
to be passed without a speculum the dorsal position is the 
most convenient. The index finger is introduced into the 
vagina and held in contact with the cervix ; the sound is 
taken in the other hand and introduced along the palmar sur- 
face of the finger that is in the vagina until it reaches the ex- 
ternal os, into which it is guided by that finger-tip. No force 
should be used as it is gently carried along. When the sound 
has passed the length of the cervical canal and reaches the 
inner os, some resistance may be encountered, either from 
the curvature of the uterine canal or from a constriction of 
the internal os. The instrument may become caught in the 
rugae in the endocervical mucous membrane at any point in 



UTERINE DISPLACEMENTS. 



245 



its passage. The obstruction can frequently be overcome 
by carrying the handle around in the arc of a circle in the 
manner which will be described more fully in describing the 
maneuvers employed in passing a sound in cases of ante- 
flexion of the neck and body of the uterus. 

If the sound is to be passed with the patient in the dorsal 
position through a speculum the method is comparatively 
easy. In this posi- 
tion the bivalve spec- 
ulum is used. The 
sound is thoroughly 
cleansed, bent to the 
proper curve, and 
anointed with some 
lubricant. It is then 
introduced through 
the speculum by 
sight to the internal 
os. If the direction 
of the canal is known 
to be normal the point 
of the instrument 
should be forward as 
it enters the cervix, 
and it enters the ute- 
rus without obstruc- 
tion by the depress- 
ing of the handle in the direction of the anus. Figure 62 
represents a normal uterus into which a sound has been 
passed and is held with its point at the fundus. 

If difficulty is experienced fo introducing the sound in the 




Fig. 62. Sound in Normal Uterus. 



246 



MODERN GYNECOLOGY. 



I 



manner above described, it is because of spasm at the inter- 
nal os, stenosis of the cervix, or deviation in the direction of 
the canal. If spasm is the cause a firm, persist- 
ent pressure for a short interval will cause the 
circular muscles to relax, and the sound will 
then enter without further trouble. If stenosis 
is present the aid of a tenaculum may be re- 
quired. This instrument may also be needed 
if the mucous membrane of the cervical canal 
is thickened by swelling*. The thickening of 
the endocervical mucous membrane may inter- 
fere with the passage of the sound, either by 
increasing the depth of the rugae or by narrow- 
ing the lumen of the canal. In the case when 
the end of the instrument gets caught in the 
folds of the swelled membrane, it is better to 
try to get past it by manipulation than to use 
force 5 but when the canal is simply narrowed 
by it some pressure may be used without injury. 
The tenaculum is needed to make counter-pres- 
sure when force is required. The tenaculum for 
this purpose should have a point with two an- 
gles, and should be strong and sharp. The in- 
strument shown in Figure 63 has these neces- 
sary features. Figure 64 represents an instru- 
ment which has a curve instead of the angles, 
and is a form preferred by some. 

When using the tenaculum its point is caught 
firmly in the anterior lip of the cervix from within the canal, 
and the cervix drawn downward and forward. In thus using 



UTERINE DISPLACEMENTS. 



247 



the tenaculum care must be taken to avoid two things: the first 
is taking too shallow a hold into the tissues of the cervix, 
and allowing the point to tear out making a ragged wound, 
and the other is allowing it to slip or tear out suddenly when 
the uterus has been drawn down, thus letting the womb re- 
turn to its position with a sudden jar. The latter of these 
accidents is a frequent cause of inflammation around the 
tubes and broad ligaments, which is attributed to the act of 
passing the sound, although this act had nothing to do with 
the pelvic involvement. If much force is required it is best 
to stop, as injury may be done. Much can be done by chang- 
ing the curvature of the sound, first bending it a little more 
and then a little less, until the right shape is obtained. The 




Fig. 65. Introduction of a Sound : First and Second Steps. 



passing of the sound must be done slowly and with care j it 
should never be undertaken in a hurry. 
When a sound is to be passed into a uterus with anteflexion 



248 MODERN GYNECOLOGY. 

of the neck and body, some different manipulations are called 
for. The tenaculum may draw the cervix into position but 
cannot completely restore the canal to its normal shape. Some 
maneuver is necessary to get the point of the sound around 
the angle. I shall use the diagram in Figure 65 to show the 
first and second steps of this process. The sound is intro- 
duced with its point backward and caused to enter as far as 
the internal os. This brings it to the position CC in the 
diagram. The handle is then carried to the right, describing 
a semicircle CD. It is noted that the point of the instrument 
has not changed its position but has only turned upon its 
axis. The outer end of the cervix is depressed by this move- 
ment, lessening the amount of deviation from the normal in 
the direction of its canal. The third step is seen in Figure 
66. The handle D is carried downward and backward to F, 
while the point goes from C to E, completing the introduc- 
tion. It is evident from the diagram that the canal is 



Fig. 66. Introduction of a Sound: Third Step. 

straightened considerably when the sound reaches the fun- 
dus. Where adhesions exist binding the fundus down to the 
peritoneum between it and the bladder, this will stretch or 



UTERINE DISPLACEMENTS. 249 

break them and may set up a pelvic peritonitis if too much 
force is used. 

Where any variation from its normal direction exists in 
the uterus, various modifications of the plan described above 
may be successful. 

Where it is deemed advisable to use a sound with the 
patient in Sims 7 position a Sims or a Cleveland speculum is 
used. A retractor is needed to push the anterior vaginal 
wall forward to get the cervix into view; when this is 
caught firmly by a tenaculum, the retractor is laid aside, or 
it may be held by an assistant if one be present. In this 
position the maneuvers are precisely the same as in the dor- 
sal position. Change in the shape of the sound may be 
needed, turning of the sound handle to pass an angle may 
be indicated, or gentle pressure to overcome spasmodic clos- 
ure of the internal os may be required. In all efforts at 
passing a uterine sound the greatest gentleness is necessary 
and no great force must be used. It is particularly danger- 
ous to resort to any proddings or sudden jerking movements. 

When the uterus has been entered the instrument must 
be passed slowly in, and the peculiar elastic sensation com- 
municated to it by the fundus watched for. When this is 
felt all pressure must stop at once. The sound has fre- 
quently been passed through a soft friable uterus into the 
abdominal cavity. This accident may do little damage if 
the sound is small, but it is dangerous. A sound has also 
been passed out through a patulous tube ; this is even more 
dangerous, as the opening is larger, making it easier for 
septic material to be carried into the abdominal cavity. It 
js well to remember that one tube may be so enlarged as to 



250 



MODERN GYNECOLOGY. 



be mistaken for a continuation of the uterine cavity j I have 
seen a curette passed into such a tube up to the handle. 
This accident may do no harm if the uterus is free from 
septis and the cervix is sufficiently open to drain 
it. The uterine probe (Fig. 67) is a smaller in- 
strument, and can be used in the same way as 
the sound. If the cervix is very narrow it may 
be required, but it is more liable to get caught 
in the irregularities of the canal walls. The 
sound is the better instrument for general 
use. 

The Treatment of anteflexion is largely me- 
chanical. This is especially true of the con- 
genital variety. The first care must be for ad- 
hesions binding the organ in its mal-position. 
These are only present where there has been a 
pelvic peritonitis. 

If adhesions are found of sufficient strength 
to make their rupture dangerous, their removal 
must be attempted by vaginal applications of 
liquor f erri persulphatis, tincture of iodine, elec- 
tricity, etc., followed by tampons saturated with 
glycerine or glycerine-borax solutions. These 
remedies have a solvent action on pelvic adhe- 
sions, and should be thoroughly applied to the 
vaginal vault two or three times each week. 

Fig. 6T. wyetvs The vaginal mucous membrane must be care- 
uterine Probe. 

fully watched and applications made further 
apart if it is found much inflamed from the last treatment 
when the patient makes her next visit. 



UTERINE DISPLACEMENTS. 251 

Proper placing of the tampons will aid the solvent action 
on the adhesions. They mnst be so placed as to cause the 
fundus to pull upon these bands, making them tense. This 
is done by following the instructions for uterine replace- 
ment. In replacing an anteflexion the finger presses against 
the posterior side of the cervix, drawing it forward and 
slightly downward. This causes the other end of the uter- 
ine lever (the fulcrum being near the internal os) to move 
backward and upward. If tins mechanism is kept in mind 
no one will think of following the advice of those who sug 
gest putting the tampon in front of the cervix for anteflex- 
ion, as they say, to cause the mucous membrane of the 
anterior vaginal wall to pull the cervix after it. Who would 
use an elastic sheet to draw on his lever when he can get 
behind it and push ? 

From this it is plain that the main tampon to relieve ante- 
flexion must go posterior to the cervix, and its size must be 
nicely adjusted to fit the place it is to occupy " snug," so as 
to exert some pressure. The fixed point for the tampon is 
the hollow of the sacrum, and it must be large enough to fill 
the space between that bone and the cervix. 

After this tampon is in proper position others smaller in 
size should be placed about the vagina as room permits. 
They should exert some pressure on the vaginal roof and fill 
its cavity sufficiently to prevent the chief one from being 
displaced until it is removed. If properly introduced these 
tampons can be worn for from twenty-four to thirty hours. 
If the adhesions do not -yield to the above hue of treatment 
a few applications of galvanism may dissolve them, or cause 
them to become so attenuated that it is possible to replace 



252 MODERN GYNECOLOGY. 

the fundus without setting up a new attack of pelvic inflam- 
mation. The electricity should be applied to the vaginal 
vault with a small metal electrode, the other pole being 
applied over the lower abdomen with a clay electrode or 
large abdominal sponge. The negative element is usually 
applied within, unless there is tendency to uterine hemor- 
rhage, when the positive pole must be used within. It is 
frequently better to alternate the current, using one pole for 
a minute and then reversing for another minute. The appli- 
cations should last from five to fifteen minutes, and sittings 
should not be given of tener than twice a week. The inten- 
sity of the current is best gauged by the patient, being always 
just a little less than painful. Should the electricity also fail 
to remove the adhesions, it may be necessary to give the 
patient ether, and passing a sound to forcibly raise the uterus 
from its bed and support it there on a stem of some kind. 
Care must be taken to ascertain if there is any tubal com- 
plication before this is attempted. While salpingitis is not 
a positive contra-indication to this operation, it renders it 
a much graver matter. These enlarged tubes may be im- 
bedded in the adhesions, and their walls may be thinned by 
pressure from the accumulated pus within. Too forcible 
manipulation may rupture such a tube, causing a purulent 
peritonitis, which will rarely be confined to the pelvis. If 
the general peritoneal cavity should be invaded by this pus, 
a fatal result will usually follow. Those cases complicated 
by diseased appendages are best left without such radical 
efforts at replacement until this more serious condition is 
relieved. 
Having succeeded in restoring the anteflexed uterus to its 




UTERINE DISPLACEMENTS. 253 

normal position, the question arises, how to keep it there. 
The answer has usually been, a pessary • bnt no gynecolo- 
gist of considerable experience is altogether satisfied with 
this appliance. It is yet a question if pessaries are not more 
of a curse than a blessing to suffering womankind. 

Anteflexion pessaries have been invented by Graily Hewitt 
(Fig. 68), Thomas, and others ; but many think that the time 
to use a pessary is when every other 
means has been tried and failed. 

Wylie recommends the tampon to 
keep the uterus in its restored position. 
If these are applied as suggested above, 
bearing in mind the mechanics of the Fig. 68. Graily Hewitt's 

Pessary. 

condition, much good will result. The 

tampons must not be too large, and a number of them thor- 
oughly saturated with boro-giycerine solution should be 
carefully placed around the cervix, giving it support on all 
sides, enough of them being used to press against the bony 
pelvis all around. The precautions are to avoid direct pres- 
sure on the rectum or urethra, which might interfere with 
the evacuations from the bladder or colon. These tampons 
can be applied three times a week and worn about thirty 
hours. They can then be taken out before retiring, and a 
hot vaginal douche taken to give tone to the organs, fol- 
lowed by rest in bed, on the back if possible. 

A few months of this treatment, if carefully done, remem- 
bering that each tampon is part of a piece of mechanism and 
has a duty to perform, will usually make a permanent cure, 
the ligaments having recovered their tone sufficiently to 
hold the uterus in its normal position, provided it has been 



254 MODERN GYNECOLOGY. 

restored to its normal size and condition by relief of the me- 
tritis, subinvolution, or tubal disease that caused the mal- 
position. 

Congenital anteflexion has yet to be considered. It needs 
a special line of treatment because of its cause. There is a 
hard, undeveloped area in the anterior wall at and immedi- 
ately above the internal os, as a cause of the faulty shape of 
the uterus. There is frequently a stenosis of the internal os 
and possibly of the whole cervix, with small " pin-hole " os. 
There may be elongation of the cervical portion of the uterus. 
Treatment of congenital anteflexion with stenosis has two 
objects in view : to make the canal patulous by curing the 
stenosis, and to soften and develop the hard, undeveloped 
anterior wall. The stenosis is relieved by dilatation, either 
gradually or by rapid divulsion under anaesthesia. The 
anterior uterine wall is softened and caused to grow by 

causing an increase in its 
blood-supply to promote its 
nourishment. 

When rapid divulsion is 
done for the stenosis the ute- 
rus is raised to its natural 
position, and is retained either 
Fig. 69. Thomas 1 ut^me stem and *>y a stem or a pessary, or 

both. The most popular stem 
is that of Thomas, which consists of a solid glass rod with a 
round, flat enlargement at its lower end. The end fits into a 
specially constructed pessary, which must be worn with the 
stem to keep it in position (Fig. 69). In order to meet the ob- 
jection that this instrument may possibly close the canal and 
prevent the exit of the menstrual blood and other discharges, 




UTERINE DISPLACEMENTS. 255 

vertical grooves have been made in its sides. If the con- 
tractions on the stem are great enongh to canse retention 
with the stem, they certainly will be sufficient to press the 
soft mucous membrane into these shallow grooves and pre- 
vent them from acting as drains. 

Thomas has devised a small instrument that he uses to 
enlarge the canal before introducing his stem. It is a probe- 
pointed instrument, with cutting edge on one side. He in- 
troduces this until its point is within the inner os, and makes 
a vertical incision the length of the cervical canal. This in- 
cision is usually about one eighth of an inch in depth. The 
instrument is then made to revolve one foiu'th of a circle 
and a similar cut made. Two more incisions are made, one 
opposite to each of these already described. It is necessary 
to do this operation under aseptic surroundings. 

The position of the uterus is restored, the stem inserted 
into the canal and extending high enough into the uterus to 
hold it upright ; the pessary is then inserted and adjusted 
to hold the stem in position. These stems can be worn for 
a number of months if they produce no symptoms. They 
need the care and precautions that must be observed with 
any pessary. Frequent douches are necessary to keep the 
vagina cleansed, and erosion must be watched for. 

Professor Thomas has also made a "galvanic" stem to be 
worn in these cases. 

Dr. Paul Outerbridge invented a wire drain for sterility 
and stenosis, which has also frequently been used as a stem 
for the cure of anteflexion. It consists of a continuous piece 
of gold wire so curved upon itself as to make a drain. Four 
vertical shafts of wire form the upright portion. These are 
bent outward at the upper end, where they form a loop at 



256 



MODERN GYNECOLOGY. 



Fig. 70. 



either side, in such a manner as to form a projection which 
can rest above the constriction at the internal os and hold 
the instrument in place. The loops joining the lower ends 
of the vertical wires are bent to form a right angle with 
them, and by resting against the end of the cervix serve to 
keep the instrument from entering the uterus (Fig. 70). 
These drains can be made of sufficient length and weight to 
support the uterus in its upright position, though they were 

originally intended for the treat- 
ment of stenosis and resulting 
sterility. 

In order to meet the objection 
of possible sinking into the tissues 
which occasionally occurs with the 
wire drain when used as a stem, 
Dr. Outerbridge has recently per- 
puterbridge's^Vire fected a stem on a similar prin- 

rain. Fig. 71. Outerbridge"s . . Tj . J „ J . J .. 

Drain Bent for Anteflexion. Ciple. it COUSlStS 01 two lateral 

blades with outward curves at the points to catch on the in- 
ternal os, and an angle at their junction to rest against the 
external os. Both of these instruments allow of perfect 
drainage and can be worn indefinitely. Being made of 
fourteen-carat gold, they will not corrode. They may be 
bent to suit the curvature of the canal where it cannot be 
completely straightened. Figure 71 is a gold wire drain 
bent to suit an anteflexion. When the uterus is raised from 
its anteflexed position a thorough curettement is usually of 
benefit. This will cure the metritis so frequently present. It 
should be followed by an application of carbolic acid to the 
denuded surface. 




Fig. 70 
D 



UTERINE DISPLACEMENTS. 



257 




The nourishment of the impaired anterior wall can be 
improved by the frequent passage of sounds or graduated 
dilators, and application of 
tincture of iodine, either 
pure or mixed with an equal 
amount of creosote. These 
applications are made on a 
uterine applicator, one every 
third day. This treatment 
will also aid in the gradual 
restoration of the fundus to 
its normal position. 

When a congenital ly ante- 
flexed uterus is straightened 
and a stem is not used to hold 
the organ in place, it can be 
retained either by tampons or pessaries, as has been de- 
scribed in the treatment of acquired anteflexion. 

When the uterus is fixed 
in its abnormal position it 
may be best to introduce 
a drain to relieve the dys- 
menorrhea, and let her 
wear it leaving the ante- 
flexion unreduced. An an- 
teflexion of the body is 
thus relieved in Figure 72, 
and an anteflexion of both 
the body and the neck is 

Fig. 73. Anteflexion of Body and Neck, , , -, • ri 

with Drain in Position. treated m like manner m 



Fig. 72. 



Anteflexion of Uterine Drain 
in Position. 




258 



MODERN GYNECOLOGY. 



Figure 73. An Outerbridge drain curved to fit the canal is 
used in each case. 

When the anteflexion of the body and neck is extreme and 
cannot be restored, some operation may be required. This 
is especially the case when much pain is present at each 

period and a drain can- 
not be introduced. In 
cases of this character 
Emmet advises discis- 
sion on the lines indi- 
cated in Figure 74. By 
this operation an artifi- 
cial external os is made 
on the posterior wall of 
the cervix. A drain or 
stem is needed to keep 
the new canal from unit- 
ing. Amputation of the 
cervix is claimed to be 
even better for these cases than discission. It is a simpler 
operation. 

Posterior Deviations of the Uterus. — Retro-displacements 
are the most frequent deviations met with. They are either 
retroversions or retroflexions, the latter being much more 
common than the former. The uterus, as has already been 
stated, is held in place by the broad, round, and utero-sacral 
ligaments. These ligaments all contain a certain amount of 
muscular tissue, making them elastic. When for any reason 
this muscular tissue loses its tonicity, the ligaments offer less 
resistance to any effort to displace the uterus, and displace- 




Fig. 74. Discission for Anteflexion of 
Body and Neck. 



UTERINE DISPLACEMENTS. 259 

ment results in a direction dependent on the ligaments in- 
volved and the force tending to make it. One cause of loss 
of tone in the ligaments is overwork due to excessive draw- 
ing upon them, usually caused by a metritis following sub- 
involution or other cause, or the sagging of large heavy 
appendages. Another common cause is atrophy of the liga- 
ments, the result of a general condition of mal-nutrition and 
flabbiness of the muscular system of the whole body. This 
atrophy may also be due to tension resulting from a mis- 
placement caused by sudden accidental force and remaining 
unreduced. 

Retroversion is a retro-displacement of the uterus in 
which the fundus is turned backward without the organ 
being bent at any point. The axis of the retroverted uterus 
is a straight line, but has ceased to 
occupy its normal relation to the axis 
of the pelvis. There are various de- 
grees of retroversion, usually spoken 
of as first, second, and third. They 

Fig. 75. Retroversion. 

are of no special importance except 

for clinical records. In Figure 75 the uterus is retroverted 

in about the third degree. 

Causes. — Retroversion may be caused by metritis, due 
either to subinvolution or other cause. The weight of the 
enlarged fundus overcomes the resiliency of the round liga- 
ments, which lose their elastic force from the prolonged 
stretching. The drawing of heavy displaced appendages 
may produce the same result. Other causes are prolonged 
rest on the back, as in long illness, falls, alighting on the 
buttocks, or tumor of the fundus or body of the uterus. 




260 MODERN GYNECOLOGY. 

The retroverted uterus may be bound down by adhesions 
that have resulted from a peri-salpingitis or pelvic peritoni- 
tis. This pelvic inflammation is in many cases a sequence 
of the same tubal disease that caused the displacement by 
the heavy appendages drawing the fundus out of its normal 
position. The organ may also become fixed by enlargement 
after displaced, its return to a normal position being pre- 
vented by its increased size. 

Symptoms. — There may be pain if the version is suddenly 
acquired, but frequently the only symptoms present are those 
due to the condition causing the retroversion. The compli- 
cating metritis or pelvic inflammation usually present will 
account for all the symptoms found. Sterility is usually 
present with retroversion, and there may be tenesmus of the 
rectum or bladder. 

The Diagnosis is usually plain on examination. The finger 
in the vagina meets the cervix, pointing anteriorly toward 
the vaginal outlet. The fundus is found far back in the 
posterior part of the pelvis. There is no angle in the uterine 
axis, as mapped out by the finger at the side. If movable, 
the uterus can be tipped forward by pressing downward and 
backward on the cervix. If there is fixation it cannot be so 
replaced. In these fixed cases there may be doubt as to the 
diagnosis, as the mass behind might be a tube, a hydrocele, 
a fibroid, a mass of peri-uterine inflammation, or an abscess. 
The fluctuation in the abscess or from fluid pent up in a tube 
will, when detected, prevent these conditions from being con- 
fused with retro-deviations. If doubt exist, a rectal exami- 
nation will often enable the fundus to be made out in the 
cul-de-sac of Douglas. If this does not make the diagnosis 



UTERINE DISPLACEMENTS. 



261 



clear, the bimanual examination or examination with the 
sound will remove all uncertainty as to the condition. The 
latter instrument gives evidence that it is unmistakable. A 
mass of feces in the rectum has been mistaken for the fun- 
dus in retro-displacement. It is evident that a rectal exam- 
ination was not made when this 
occurred. 

Anteflexion of the cervix has 
been mistaken for retroversion, and 
vice versa, the position of the cer- 
vix being about the same in each. 
This error cannot occur when the 
position of the fundus is made out, 
as it always should be before the diagnosis is decided upon. 

Treatment of retroversion is the same as retroflexion, except 
occasionally the angle in the latter requires some additional 




Fig. 76. Thomas-Hewitt Re- 
troversion Pessary. 




Fig. 77. Retroversion before Restoration. 



consideration. Thomas' modification of Hewitt's pessary 
(Fig. 76) is frequently worn with benefit. The position may 
be restored by placing the patient in the genu-pectoral posi- 



262 MODERN GYNECOLOGY. 

tion, as shown in Figures 77 and 78, or by the pressure of a 
finger on the anterior of the cervix. The organ can be re- 
tained in its normal position by tampons or by a pessary. 




Fig. 78. Retroversion replaced by Genu-pectoral Position. 

Retroflexion. — The uterus is displaced backward and at 
the same time bent upon itself when retroflexion is present. 
A frequent . position is for the fundus to fall over into the 
cul-de-sac of Douglas, the cervical portion remaining in its 
normal position (Fig. 79). When the fundus is further de- 
pressed there is usually some change in the position of the 
cervix. It is carried forward and upward into the anterior 
vault of the vagina. 

Causes. — Retroflexion differs from anteflexion in that it is 
rarely congenital, though it may appear in the virgin from 
metritis, constipation, or masturbation. The majority of cases 
is due to causes following pregnancy. E. Martin claims 
subinvolution of the anterior uterine wall, due to attachment 
of the placenta there, as a cause. The weight of the uterus 
immediately after delivery may cause retroflexion if allowed 
to act continuously. A case of primapara under my care 



UTERINE DISPLACEMENTS. 



263 



persisted in remaining in bed for three weeks after her child 
was born, and was on her back almost all that time. She 
had no mal-positioii prior to her accouchement, but got up 
with a marked retroflexion without tubal disease, metritis, 
or subinvolution. There were no adhesions or other com- 
plications, and no causal factor but the prolonged rest on 
the back could be found. 

Relaxation of the broad and round ligaments lessening the 
supports of the fundus, while the stronger utero-sacral liga- 
ments hold the cervix in position, is the usual condition 




found in retroflexion. The causes of this relaxation are a 
too heavy fundus, displaced appendages, or impaired general 
nutrition. If the appendages have not been displaced before 
the uterus causing the retroflexion, they may be drawn down 
with it into Douglas' pouch and become involved in adhe- 
sions there. These bands of adhesions are frequently strong 
and firm, and may bind the fundus, the ovaries, and the 



264 MODERN GYNECOLOGY. 

tubes firmly together. They may draw upon the nerves and 
produce many of the symptoms of reflex nature commonly 
met. Paraplegia has been produced in this manner. Irre- 
ducible cases are as a rule complicated by salpingitis, the 
adhesions being due to inflammations around the tubes glu- 
ing the parts together. 

The Symptoms of retroflexion are the usual symptoms of 
uterine disease, called by Pozzi " the uterine syndroma," and 
elsewhere described, nervous reflexes, and sterility. Obsti- 
nate constipation and the fecal anaemia of Sir Andrew Clark 
are common, the one being a sequence of the other. Statis- 
tics also show that about ten per cent of the women with 
retro-deviations have excessive loss of blood, either as metror- 
rhagia or menorrhagia. It is a question if the cause of the 
hemorrhage causes the misplacement, or if the extra loss of 
blood is a result of the faulty position of the uterus. 

The nervous reflexes may assume one of many forms. 
There may be neuralgias, '''nervous" coughs, dyspepsia, hys- 
teria, chorea, asthma, vomiting, aphonia, hystero-epilepsy, 
or paraplegia. The latter will interfere with walking and 
confine the patient to bed or to her chair. All of the above 
conditions have been observed with retroflexion and have 
ceased after straightening up the uterus. 

Sterility is common, but should pregnane}^ occur it may 
cure the condition, provided the adhesions yield. If they are 
firm enough to prevent the rise of the fundus out of the 
pelvis, abortion will result, leaving the condition worse than 
before the pregnancy occurred. 

The examining finger detects a tumor in the pouch of 
Douglas and also notices the absence of the fundus in its 



UTERINE DISPLACEMENTS. 265 

normal position. Unless there is much thickening from 
adhesions, there is no need of a bimanual examination or the 
sonnd to make the diagnosis perfectly clear. The outline of 
the entire uterus can be accurately made out with the one 
finger in the vagina, so that no doubt should remain in the 
mind of the examiner. The angle near the position of the 
internal os distinguishes it from a retroversion. The posi- 
tion of the cervix is also different from the latter condition, 
being normal or nearly so. 

If doubts exist, rectal examination should be made to re- 
move them, and when necessary the hand on the abdomen 
or the sound can be used. It is well to note the amount of 
retroflexion existing and the mobility of the uterus at the 
same time. The degree to which the organ can be moved is 
ascertained in the same manner as in retroversion, by pres- 
sure upon the anterior of the cervix. The amount of lateral 
motion produced by pressure can be learned by the finger at 
the side of the angle. 

Treatment. — If the retroflexed uterus is bound down by 
adhesions these must first receive attention. The manner 
of their absorption and the remedies most likely to produce 
this result have been described under the treatment of ante- 
flexions. The complications must receive treatment at the 
same time. Metritis may call for intra-uterine applications as 
already detailed, and curettement may be necessary. When 
the latter treatment is resorted to the endocervical mucous 
membrane must receive attention as well as that lining the 
fundus and around the internal os. This should be followed 
by a thorough application of some caustic to the entire sur- 
face denuded. The best remedy is carbolic acid, either pure 



266 MODERN GYNECOLOGY. 

or dilute one half with glycerine. If the cervix has been 
lacerated it must be treated after the manner described in 
the chapter on metritis. After intra-uterine applications a 
patulous canal must be provided by dilatation if there is 
stenosis, or by avoiding too radical closure if sutures are 
required. All these manipulations must be done with the 
utmost gentleness, to avoid any possibility of starting up in- 
flammation in the pelvic peritoneum. 

Salpingitis and pelvic peritonitis must receive hot douches, 
iodine and creosote to the cervix and vaginal roof, glycerine 
tampons, etc., until all acute symptoms have ceased before 
any active interference is begun. Unless urgency of sepsis 
in the uterus exists, there is always time to await the relief 
of the acute tubal and peri-uterine inflammation before in- 
terference with the endometrium. After the adhesions are 
absorbed and the metritis and cervical conditions have all 
been relieved the question of reposition requires considera- 
tion. There are various methods of replacing a retro-dis- 
placed uterus. The first attempted should always be the 
manual. This is done in the following manner, and in 
uncomplicated cases is usually successful. The level of the 
internal os is nearly a fixed point, made so by the utero-sacral 
ligaments, and pressure downward and backward on the an- 
terior of the cervical portion will usually cause the fundus 
to swing upward into its normal position. If the angle is a 
rigid one the cervix will be pushed into an abnormal posi- 
tion at the same time and will need to be straightened either 
on a sound or a stem. The fundus may not start upward 
freely, when the cervix is pressed downward and backward. 
More pressure may be required than seems justifiable. In 



UTERINE DISPLACEMENTS. 267 

this case the finger may be passed deeper into the vagina 
and the fundus started out of its bed in Douglas' cul-de-sac. 
If the vagina is capacious two fingers may be introduced, 
and the index finger applied to the cervix to depress it while 
the longer middle finger raises the fundus. This method 
will usually suffice to reduce any retro-displacement that is 
free from adhesions. 

If the vagina is small and the fundus seems caught under 
the sacral prominence, a finger in the rectum may aid in 
pushing up the fundus. A finger of the same hand is in- 
serted and the perineum depressed by the web between the 
finger in the vagina and the one in the rectum. 

When the uterus cannot be replaced by one hand alone 
there is one of two things to do, depending on the case. If 
the patient is stout, with large, thick- walled abdomen, more 
can be done by placing her in the genu-pectoral position 
(Fig. 78). The vagina is then opened with the fingers or 
Sims' speculum by raising the perineum and allowing the 
air to enter. This gives the force of gravity a chance to act, 
and the abdominal contents fall toward the diaphragm, and 
may restore the uterus to its normal position at once without 
further aid. Should it fail to do so the finger or fingers in 
the vagina will now find little difficulty in replacing it, though 
the additional finger in the rectum is sometimes required 
even in this position. Corsets and bands about the waist 
must be removed to get the benefit of the position. 

Should the woman be thin, with flabby, easily depressed 
abdominal walls, the other hand on the abdomen may be 
called to aid the finger below, after the manner of a bimanual 
examination. The hand on the abdomen seizes the fundus 



268 MODERN GYNECOLOGY. 

and draws it forward into a position of exaggerated ante- 
flexion. This can be done with the patient either in Sims' 
or the dorsal position. It is difficult, and causes much dis- 
comfort if the patient be very stout or has rigid abdominal 
w r alls. 

Another method of reposition often used is with a sound. 
This should be done with all the precautions usually required 
for introducing a sound. The vagina and cervix must be 
thoroughly cleansed and made aseptic, as must the instru- 
ments and towels to be used and the hands of the physician. 
The sound is bent in a slight curve and introduced to the 
fundus with the curve backward. The end of the sound is 
then made to describe a half -circle, bringing the fundus 
around anteriorly. This must be done slowly, and the arc 
described by the handle must be just large enough to allow 
the point of the sound to pass round in a smaller semicircle, 
causing no motion at the inner os. After the semicircular 
movement is complete and the fundus is raised and forward, 
the handle can be depressed toward the perineum, giving the 
uterus a position of exaggerated anteflexion. 

This last method can be used through the bivalve speculum 
with the patient in the dorsal position, or with Sims' specu- 
lum with the patient in either Sims' or the genu-pectoral 
position. More force can be exerted with the sound than 
by the other methods, and the possibilities of setting up 
inflammation in the parts surrounding the uterus and its 
appendages are correspondingly greater. The sound should 
not be used in cases where the tubes contain pus or other 
pent-up fluid, or where there is acute peri-salpingitis. A 
large smooth sound should be used. 



UTERINE DISPLACEMENTS. 



269 



> 




o 



Emmet and Jennison (Fig. .80) have each invented an in- 
strument for correcting uterine flexions. The former is 
called a "repository' the latter a "sound," which can be used 
as a repositor. Dr. E. A. Kingman has combined the advan- 
tages of both in a repositor bearing his 
name. Any of these instruments may be 
used, but a large smooth' metallic sound 
will be found to answer all require- 
ments. 

Gradual reposition is best done with 
tampons of cotton or absorbent wool. 
Oakum is also used for this purpose 
Manipulation with one or more fingers in 
the vagina can be used at the same time 
before applying the tampons. The pres- 
sure exerted by the fingers must be grad- 
ual and not forcible. No abrupt force 
should be nsed. The cervix is pressed 
upon in a way to cause the fundus to 
draw upon the adhesions and attempt to 
rise from its bed to the normal position. 
Further pushing movements at the point 
of adherence directly against the fundus 
can be made also, either through the vag- 
inal or rectal wall. These efforts must 
be persisted in at each visit for weeks, and 
each time be followed by tampons to exert 
milder but prolonged pressure. Treatments should be had two 
or three times a week. After several months the adhesions 
will give way and complete reposition will be accomplished. 




Fig. 80. Jennison's 
Repositor. 



270 MODERN GYNECOLOGY. 

This uterine massage, if applied with judgment and pa- 
tience, is apt to produce good results, as it restores tone to 
the parts as well as stretches and attenuates the adhesions. 
It is a very good adjuvent to the treatment with tampons. 
It is useful in all displacements of the uterus. Its chief 
danger is in cases complicated with pyo-, hydro-, or haeinato- 
salpinx with thin walls, or with pelvic abscess, where there 
is danger of rupture into the abdominal cavity. These con- 
ditions must all be removed before attempts of any kind are 
made to remedy the displacement. 

If it is necessary to dilate the cervical canal for stenosis, it 
is usually best to use a blunt curette thoroughly over the 
whole uterine cavity, including the parts in the lower seg- 
ment and in the cervix. Of course this will only be done 
under the usual precautions and after removal of the usual 
contra-indications (see metritis), and under an anaesthetic. 

Having replaced the uterus, the next consideration is how 
to keep it there. The same is true here as of anterior dis- 
placements. The pessaries in use are not satisfactory. 
Pozzi recommends a ring of soft rubber to inflate the va- 
gina. His translator objects to this inflation or stretching, 
and advises a Hodge. Professor Wylie objects to either, and 
advises the use of tampons. It is rare to find two authori- 
ties agree on this subject except when they are pupils of the 
same teacher or one the pupil of the other. The theories of 
what a pessary is to do and the mechanism of doing it are 
as various as their advocates. 

Having no desire to advocate any, and with no pet theory 
to ventilate, it has seemed best to give brief mention of a 
few and their claims. I must remark in passing that the 



UTERINE DISPLACEMENTS. 



271 




Fig. 81. 



Flexible Ring for Molding 
Sample Pessary. 



careful and persistent use of tampons frequently applied has 
given me most satisfactory results. To get good results with 
a pessary or other appliance, exact knowledge of the cause of 
the misplacement, followed by a careful adjustment of the 
appliances to the size and 
shape of the parts, is a sine 
qua non. Hence trial pessa- 
ries should be flexible, and 
the physician should learn to 
mold them to suit the case. 
The most frequently used for 
this purpose is a ring of cop- 
per wire covered with rubber. 
A ring of flexible tin is also 
convenient. This is molded 
by the hands of the physician, and when the correct shape is 
obtained a rubber instrument can be ordered and made from 
this model. Figure 81 is a flexible metal ring covered with 
soft rubber, and can be molded by the physician's hands. 

Instruments for measuring the depth and width of the 
vagina have been invented. The length is usually taken in 
a straight line from the point behind the cervix where the 
vaginal wall unites with the cervix to the hymen at its point 
of union with the anterior vaginal wall. This distance can 
be measured on a sound or applicator, or, even better, on 
the index finger and hand, using the same thumb to indicate 
the point where the hymen or its remains touch the hand 
when the tip of the finger is at the posterior wall of the 
cervix. 

The width can be estimated by two fingers in the vagina, 



272 MODERN GYNECOLOGY. 

but better by Baker's vaginometer. It should be measured 
at the cervix, the middle of the vagina, and at the entrance 
just within the hymeneal ring. 

The curve of the pessary depends on the work to be done 
by it and the position of the uterus. If there is simple fall- 
ing a very straight one is usually advised, while if the flexion 
be marked a greater curve is made in the instrument used 
to correct the displacement. 

The theory of retroflexion pessaries needs a brief mention. 
Almost, if not quite all, instruments made for this purpose 
are constructed with the idea of acting behind the cervix. 
For instance, Albert Smith made a retroflexion pessary with 

double curve, the posterior 
bar to fit the posterior vag- 
inal fornix ; Thomas modi- 
fies it by making this pos- 
terior bar thicker; Munde 
further changes it by mak- 
ing the whole pessary shorter 
and thicker. Figure 82 is 
Emmet's modification of Smith's pessary. The same idea 
runs through all these instruments, which is to keep the uter- 
ine fundus in place by acting from behind. Some seem to 
think this is done by the instrument pushing directly against 
the posterior part of the uterine body, holding the organ up- 
ward and forward, while others claim to attain the result by 
making the posterior vaginal vault tense and causing its an- 
terior folds of mucous membrane to draw the cervix back- 
ward and upward by its attachment to this the lower end of 
the uterine lever. It is even further claimed that relaxation 




Fig. 82. Emmet-Smith Pessary. 



UTERINE DISPLACEMENTS. 



278 



of the utero-sacral ligaments may be rectified by the poste. 
rior bar of the pessary pushing upward and making them 
tense. Still others claim good from the pressure of the side- 
bars of the pessary on the side of the vaginal vault acting 
on the relaxed broad and round ligaments, and there are 





Fig. 84. Hoffman's Pessary. 



Fig. 83. Inflated-Ring Pessary. 

those who maintain that 
the retroflexion pessary 
holds the retro-displaced 
uterus in place by exert- 
ing its influence more or 

less in all these ways mentioned. The inflated-ring pessary 
(Fig. 83) acts by expanding the vagina in all directions. 
Hoffman's pessary (Fig. 84) is used in the same way. Each 
of these instruments can be made larger or smaller by 
changing the amount of air within it. 

My colleague, Dr. Paul Outerbridge, teaches yet another 
theory. He claims that retro-displacement must be cor- 
rected by force acting on the anterior of the cervix, and 
that it is better and easier to hold the fundus in place by 
pushing the Cervix backward. He often uses a regulation 
anteflexion pessary for retroflexion, and claims better results 
than with the instruments made for retroflexion. My experi- 
ence with tampons gives weight to the last-mentioned theory. 



274 MODERN GYNECOLOGY. 

It is my practice to fill the anterior vaginal fornix first, in 
tamponnading for a retroflexion, and then place the remain- 
ing pledgets around the vagina in such a manner as to hold 
the first one in place and at the same time fnlly expand the 
vaginal vault on all sides. This acts by pushing the cervix 
backward, the pubic arch being the point of fixation for the 
anterior tampon, and at the same time gets the benefit of 
any action that can be exerted upon the relaxed broad and 
round ligaments at the sides. The results from these pack- 
ings are usually satisfactory. 

Flaccidity of the vagina, when present, needs treatment 
to restore the walls to their normal condition. Applications 
of liquor Monsel in full strength will often do this. These 
applications should be copious and be followed by the tam- 
pons placed as indicated. The tampons can be saturated with 
glycerine or may be applied plain. In many cases the latter 
way is better. One fact must be borne in mind in using the 
iron : it is a powerful astringent, and puckers the parts very 
much when applied, as it should be, generously, and the 
tampons used with it must not fit too tightly, or much pain 
will be caused when this astringent action draws the parts 
together over them. The tampons will be difficult to remove 
if the attempt is made before the action of the iron has 
passed off. Care must be taken also not to further dilate 
a capacious vagina by too much tamponnading. Atrophy 
of the vaginal walls can be produced in this way. Dr. F. 
Le Roy Satterlee has had made a powder-blower with which 
he fills the upper part of the vagina with powdered tannin 
through the bivalve speculum. He repeats this every third 
or fourth day, and claims good results without either tampon 



UTERINE DISPLACEMENTS. 



275 



or pessary. Several months' treatment is required for this 
method to relieve the vaginal flaccidity. 

When all the complications have been relieved and the 
uterus replaced, if it fails to remain upright after treatment 
for a reasonable time a pessary may be the only resort left. 
There are cases where this is really the only thing to use. 

After the instrument has been molded to fit it is introduced 
in the following manner. The upper bar, or that part which 
is to rest highest in the vagina, is held at the introitus, with 




Fig. 85. Introduction of a Pessary: First Step. 

the greatest width in the line of the vulvar opening. The 
lower end of the instrument is steadied with the left hand, 
while the index finger of the right hand is applied to the 
inner side of the upper bar (Fig. 85). By gentle pressure 



276 MODERN GYNECOLOGY. 

the pessary is insinuated between the labia and carried into 
the vagina ; as it passes higher it is gradually turned until 
it rests transversely when the bar reaches the cervix (Fig. 
86). The bar is now depressed by the index finger so it 

does not catch against the cer- 
vix, and thus carried into the 





Fig. 86. Introduction of a Pessary: Fig. 87. Introduction of a Pes- 
Second Step. sary : Third Step. 

posterior fornix (Fig. 87). If the bar is to go anterior to 
the cervix the last movement is not needed. No pessary 
should be introduced until the mal-position has been recti- 
fied, nor while there is marked pain or inflammation. 

Every patient who wears a pessary should be told she has 
one, instructed how to remove it, and told to do so when- 
ever it causes any pain. She should use a daily douche of 
warm water containing sodium bicarbonate. Injections 
containing alum or any sulphate must be avoided, as they 
roughen the rubber. The instrument must be removed at 
frequent intervals and cleansed ; the vagina should also be 
thoroughly examined for erosions at intervals. 



UTERINE DISPLACExMENTS. 277 

Numerous operations have been devised for the relief of 
retroflexion. The simplest is probably that of Alexander. 
This consists in cutting down over the inguinal ring and 
finding the round ligaments 5 these are drawn down through, 
the rings until they hold the fundus steady in a position of 
partial anteflexion and are fastened there by sutures. This is 
often successful, for the time at least, in restoring the organ 
to its proper position. The round ligaments may not adhere 
after the sutures are absorbed, or if attenuated they may 
lengthen and allow the fundus to sink back into its mal- 
position again after a few months. 

Better results are claimed by laparotomists when the ab- 
dominal cavity is opened and the round ligaments are sutured 
to the abdominal wall. They put the sutures through these 
ligaments close up to their point of attachment to the uterus 
and thus leave no chance for stretching. The result becomes 
a permanent fixation of the fundus in an upright position. 
Pregnancy has occurred and progressed to term without un- 
toward symptoms in several cases under my observation in 
which this operation has been done. There has been no re- 
currence of the displacement in any of them after the preg- 
nancy terminated. 

Dr. Brathwaite has suggested and done an operation for 
persistent retroflexion which he claims will overcome the 
objections to Alexander's operation and yet avoid the neces- 
sity of opening the abdomen. His operation is done through 
the vagina. It is begun by making an incision in the an- 
terior vaginal roof between the uterus and bladder. The 
bladder and urethra must contain a sound to avoid injury to 
them. The tissues are dissected up until the uterine wall 



278 MODERN GYNECOLOGY. 

is bared on either side of the point where the peritoneum 
adheres to it. This point is lowest in the median line, and 
by going upward to either side the uterus can be exposed 
almost to the fundus. A stitch of strong silk is then put 
through the anterior wall of the fundus from side to side as 
high up as possible. The same suture is then passed deeply 
through the anterior wall at the level of the internal os. 
These sutures are drawn after the uterus has been placed 
in a position of anteflexion and tied, holding it there. The 
sutures are left to absorb. 

Many other operations have been suggested for the relief 
of retro-deviations, but they have failed of permanent results. 
The cause of this in many cases is due to the fact that they 
have been attempts to fasten the organ to flexible parts, 
the most frequent idea being the formation of cicatrices in 
the vaginal wall or attachments to it. 

Any operation or other procedure for retaining the ute- 
rus in its normal position must be preceded and followed by 
treatment to remove the causes. If the appendages have 
drawn it out of place by their weight, they must receive at- 
tention ; if subinvolution and metritis have caused it to leave 
its normal position, they must be cured ; and if the ligaments 
have failed to support it in place, treatment to restore their 
tone must be applied. All these things must be done thor- 
oughly, persistently, and with a definite knowledge of the 
objects to be attained, and success will result. 

Mollites Uteri. — Deviations of the uterus will not be com- 
plete without mention of " mollites uteri." This name was 
given to this condition by the late Dr. Charles D. Scudder, 
who was, I think, the first to describe it, This softening of 



UTERINE DISPLACEMENTS. 279 

the uterus is most marked iu its middle segment at and im- 
mediately above the internal os. At this point the organ is 
so flaccid as to offer very little resistance to the examining 
finger when pressed against it. 

Synqrtoms. — The most prominent symptom is the variable 
position of the fundus. Examination at one visit reveals a 
retro-displacement, usually a flexion, and at some subsequent 
visit an ante-displacement will be found. There is usually a 
flabbiness of the ligamentous supports of the uterus as well, 
and there is rarely any peri-uterine complications, though 
the fundus is usually heavy from metritis. There is general 
flabbiness of the tissues of the body, particularly the muscu- 
lar structures. 

Tlie Treatment must be general and local. The general 
treatment consists of tonics, as strychnia, iron, quinine, phos- 
phorus, etc., accompanied by moderate exercise in the open 
air, good nourishing food, and such drags as are needed to 
keep the alimentary canal in a healthy state. The local 
treatment consists of Monsel's solution of iron to the vagina, 
intra-uterine applications of tincture of iodine and creosote, 
if metritis is present, and tampons to steady the uterus in 
position. Hot-water douches in the intervals between treat- 
ments must also be given. 

Displacement of the Uterus en Masse may occur. This 
is always a symptom of some other condition, and merits 
no consideration except appreciation of the cause. The dis- 
placement may be lateral, anterior, or posterior, and the cer- 
vix may be more removed from its normal position than the 
fundus, or vice versd. Cicatricial tissue caused by healing 
lacerations involving the upper vagina is the most common 



280 MODERN GYNECOLOGY. 

cause of the cervix being displaced. This always draws the 
organ toward the side on which it occurs. Tumors, either 
in the tubes or around them, act most frequently on the 
upper uterine segment. They cause displacement by push- 
ing the organ to the opposite side of the pelvis. Displace- 
ments upward are always due to tumors, causing the pelvis 
to be too full, and merit no special mention. 

Prolapse of the Genital Organs. — Under this head is 
included prolapse of the vagina as well as prolapse of the 
uterus, because the displacement of the vaginal walls, as cys- 
tocele or rectocele, frequently occurs first, the uterine dis- 
placement being a consequence of these conditions. Elon- 
gation and hypertrophy of the cervix might with propriety 
be also included under the same head, as it is intimately 
associated with this condition as clinically seen. 

Causes. — Prolapsus is usually a result of pregnancy or of 
frequent pregnancies, and the greater the number of preg- 
nancies in a given case, the greater the tendency to this con- 
dition. Violence, in the form of falls, may produce it, but 
is frequently only the last cause, favorable conditions for it 
existing as a result of frequent parturitions. A few cases of 
prolapse from falls occurring in a virgin are on record, but 
they are rare. 

The great factor in downward displacement is laceration 
of the perineum destroying the perineal body. The external 
skin covering the perineum may be torn and remain apart 
without much danger of prolapse, bat when the perineal 
body is torn falling almost always follows, sooner or later. 

This perineal body is a wedge-shaped piece formed by the 
union of muscles from the sides of the pelvis, the symphysis 



UTERINE DISPLACEMENTS. 



281 



pubes, and the coccyx. This wedge supports the posterior 
wall of the vagina by continuity of tissue, and its anterior 
wall by contact, and through both walls it aids in the support 
of the uterus and its appendages. The loss of this perineal 
body removes the lowest element in this series of supports. 

The mechanism of the perineal support of the uterus is 
evident from Figure 88, which was specially drawn for this 
work. The wedge-shaped perineal body is shown between 




Fig. 88. The Perineal Body as a Support to the Parturient Canal. 



the vagina and rectum. When a considerable portion of this 
is torn backward, the posterior wall of the vagina will be in 
the form of a double ^urve. Pressure from above will cause 
the lower curve to increase, causing a bulging downward of 



282 MODERN GYNECOLOGY. 

the posterior vaginal wall. The result is prolapse with rec- 
tocele. 

The first stage of prolapse is accompanied by rectocele or 
cystocele, or both. The presence of a small amount of cellu- 
lar tissue between the walls of the vagina and rectum make 
prolapse of the posterior wall possible to a certain extent 
without carrying the rectum with it, while the intimate con- 
nection of the anterior wall of the vagina and the walls of 
bladder renders prolapse of the anterior wall without cysto- 
cele almost impossible. 

At times the peritoneum is abnormally low in Douglas' 
cul-de-sac, and a fold of it is drawn down with the wall of 
the vagina and the rectum, complicating the rectocele ; the 
cystocele may be complicated in the same way by a fold of 
peritoneum coming down posterior to the fold of bladder. 
This possibility of peritoneal communication should always 
be borne in mind in all operations or other manipulations 
resorted to for cystocele or rectocele, as the peritoneal fold 
in either may contain a loop of intestine which may be in- 
jured. 

There may be prolapse of the vagina alone, or it may be 
accompanied by elongation of the cervix. This elongation 
may be sufficient to project beyond the vulva, the fundus 
occupying its normal position. The next step in the de- 
scent of the pelvic organs is misplacement of the uterus in a 
downward direction. Three degrees of descent have been 
described, but this division is arbitrary and needless. The 
uterus "falls," if not checked, until the cervix appears at 
the vulva. If the perineum is torn badly and no treatment 
is had, the whole uterine cervix may be beyond the labia 




UTERINE DISPLACEMENTS. 283 

majora ; but it usually returns within the vagina when the 
patient is in a recumbent position. 

In very bad cases there may be partial or complete inver- 
sion of the uterus, varying from a slight depression of the 
fundus to the presentation of the endome- 
trium lining the fundus at the introitus va- 
ginae as a rounded tumor. This inverted 
uterus has been mistaken for a uterine 
fibroid with a long pedicel, and operation has 
been attempted for its removal before the 
true condition was apprehended. As a rule, 
careful examination will avoid such disas- Fig. 89. inversion 

of the Uterus. 

trous blunders, as absence of the fundus in 

its usual position can usually be ascertained. Figure 89 is a 

uterus in an early stage of inversion. 

In all cases of pronounced downward displacement where 
the mucous membrane of the vagina covering cystic or rectal 
tumors or the cervix projects externally there is a tendency 
to erosion and the consequent formation of " ulcers." These 
are not ulcers in the sense that they are formed by any ul- 
cerative process. They are simply raw surfaces where the 
mucous membrane is wanting, having been removed by 
friction or want of nutrition resulting from the abnormal 
position. 

The ovaries may be involved in the prolapsus. The usual 
position of these organs when involved is behind the uterus, 
in the fold of peritoneum constituting the pouch of Douglas. 
In cases of inversion they are apt to follow the uterus into 
the depression formed by it ; this is only common in cases of 
complete inversion, as they are at times held up by their liga- 



284 MODERN GYNECOLOGY. 

mentous attachments even after the fundus is turned inside 
out. Prolapse of the ovaries may occur without displace- 
ment of any part of the parturient canal, and will receive 
mention in the chapter devoted to these organs. 

Symptoms. — The diagnosis of downward displacement is 
often made by the patient herself. She feels the cervix or 
the prolapsed vaginal wall at the vulva, and comes for assist- 
ance, saying she has " falling of the womb." This statement 
of hers is often correct, but not always, as any other tumor 
presenting there will cause her to make the same statement. 
Occasionally there is no reason for her statement at all, as 
women have a dread of this condition and may be led to 
think they have it by their fears. Other symptoms com- 
plained of are backache and dragging pains in the pelvis, 
back, and inguinal regions, rectal and cystic tenesmus, and 
there may be dysmenorrhoea. Frequently there is too much 
blood lost, either by prolonged or copious menses or too fre- 
quent occurrence of the flow. 

Examination. — If there is cystocele or rectocele a rounded 
tumor shows at the vaginal outlet on parting the labia, the 
crease showing the location of the vaginal canal being behind 
it in the former and in front of it in the latter condition. A 
sound passed into the bladder can be returned into the tumor 
when that viscus is involved, and a finger passed into the 
rectum can be carried around forward in the same manner 
when its anterior wall is involved in the tumor. The tumor 
can be readily pushed back by the finger, only to return 
when the pressure is removed. The rough transverse mark- 
ings in the mucous membrane formed by the ruga? will help 
to distinguish it from other tumors presenting at the vulva, 



UTERINE DISPLACEMENTS. 



285 



The sound through the bladder or the finger through the 
rectum are diagnostic. 

Digital examination will detect any displacement of the 
uterus, the cervix being found lower in the vagina than is 
normal. There is apt to be present a general laxness of the 
walls of the vagina and the uterine supports, allowing con- 
siderable liberty of motion to that organ and its appendages. 
If there is inversion the fundus will be missed by the finger 
in following up its side. Its absence will also be noticed on 
rectal examination, the abdominal hand will detect the " dip " 
in the fundus when examining bimanually, and the uterine 

sound cannot be in- 
troduced. A mucous 

fibroid at the fundus 

(Fig. 90) may create 

the impression of an 

inversion. The sound 

will be particularly 

liable to deceive in 

cases like the above. 

The hand on the ab- 
domen will find the 

depression in the fun- Fl &r%' x sSating in e 

dus if present, show- 
ing the importance of a bimanual examination in doubtful 
cases. If the inversion be far enough advanced the fundus 
may be felt presenting through the external os into the va- 
gina as a rounded tumor, and resembles a polyp at times. 
Figure 91 is a fibroid at the cervix resembling an inverted 
uterus. A bimanual examination here reveals the fundus in 




Fig. 90. Mucous Fi- 
broid at the Fundus 
Simulating Inver- 
sion. 




286 MODERN GYNECOLOGY. 

its normal position, and with patience a sonnd can be passed. 
The bimanual examination should be used and all other 
available methods of examining before a decision is made or 
treatment begun. 

Treatment of the minor forms of prolapse is often success- 
ful without operation. It consists in reposition and support 
of the displaced organs, the application of remedies to restore 
tone to the relaxed supports, and the use of such means as 
are required to improve the general health. 

The replacement of the organs is usually easy, and can be 
done with one or more fingers in the vagina. The reposi- 
tion of inversion is more difficult, and will receive separate 
consideration later. Frequently the parts replace themselves 
when the patient is in the dorsal position. Reposition is 
aided by the knee-chest position, and often the patient can 
be taught to assume this position herself, admitting the air 
by separating the labia. This allows the parts to resume 
their usual position due to the action of gravity. A valuable 
auxiliary to other forms of treatment for misplaced genital 
organs is to have the patient place herself in this position 
several times daily and remain in it as long as she comforta- 
bly can. 

The means of keeping the parts in their restored position 
are not so satisfactory. Pessaries are frequently used, but 
the same objections obtain in these cases as in antero- or 
postero-displacements. The tampons, properly used, are usu- 
ally more satisfactory. This is more noticeably so as their 
use allows the frequent applications of remedies to relieve 
the relaxation of supporting parts. The tampons should be 
small, and placed about the vagina in such position as to 



UTERINE DISPLACEMENTS. 287 

retain every part in its restored position. If there is prolapse 
of the posterior wall it must be drawn upon by filling the 
posterior fornix first. The anterior wall is held np in like 
manner by packing the anterior vault of the vagina first. 

The introduction of the tampons must be preceded by the 
application of some astringent to the whole vagina. The 
best drag for this purpose is the persulphate of iron (Mon- 
sel). Tincture of iodine and creosote has some astringent 
action, and is more satisfactory in some cases when the iron 
causes pain or too much sloughing, but it is not as likely to 
penetrate deep enough to affect the ligamentous supports 
where they are relaxed, nor are its effects so lasting as the 
iron. The tampons should be saturated with the following 
solution : 

Alum. 
Borax. 

Glycerine aa § ij 

M. 

Where there is inversion the restoration is more difficult, 
depending upon the degree of inversion and whether there 
is prolapse as well. The inversion may exist when there is 
no displacement of the vagina, or it may be complicated by 
vaginal prolapse. 

If adhesions have formed in the pelvis after the displace- 
ment occurred, it may be impossible to replace the uterus or 
to correct the inversion. When the inversion is partial it 
can frequently be pushed up by careful manipulation with 
one or more fingers in the vagina. If the inversion is 
complete Tait introduces a finger of one hand into the 



288 



MODERN GYNECOLOGY. 



rectum and the corresponding finger of the other hand into 
the bladder. These fingers are passed to above the point 
of uterine attachment to the anterior and posterior vaginal 
walls, and their palmar surfaces made to press downward at 




Fig. 92. White's Method of Restoring an Inverted Uterus. 

these points to oppose the pressure from below. The thumbs 
of both hands are now applied to the inverted fundus and 
press it upward through the cervix to its normal position. 
White's method of restoring an inversion of the uterus and 
his instrument is shown in Figure 92. 

If the cervix has contracted after the fundus is entirely 



UTERINE DISPLACEMENTS. 289 

through it, it may be impossible to get the parts restored to 
their natural position. The cervical ring has been incised 
and the fundus pushed upward with the hand, allowing it to 
tear open as much more as is required. After the parts are 
replaced the laceration is repaired. This is a serious opera- 
tion, requiring a skilled surgeon. The abdominal cavity 
may be opened in doing it. It may be wisest to do a lapa- 
rotomy and attach the fundus to the anterior abdominal 
walls after it has been put up into its normal position. 

Intra-uterine packing may be necessary to retain the posi- 
tion after it has been restored, and the endometrium should 
be treated as its condition indicates. In cases where the 
inversion cannot be corrected the fundus may be removed. 
In doing this the possibility of opening the peritoneal cavity 
must not be overlooked. 

The use of a pessary or tampons presupposes the presence 
of at least a part of the lower segment of the pelvic floor, in 
which the perineal body is so important a factor. And this 
brings up the various methods of restoring the genital sup- 
ports by operations. 

The first and vastly the most important of these are those 
for restoration of the perineal body. It is not the object of 
this book to give in detail descriptions of important opera- 
tions. Many good methods have been devised for closing 
lacerations of the perineum. The main desiderata are that 
the operation should be short, and that the muscular struct- 
ures be thoroughly denuded and well united, making a com- 
pact perineal body. Complete junction of the skin makes a 
nice-looking result, but it may conceal a failure, just as an in- 
tact external perineum may conceal a tear that has destroyed 



290 MODERN GYNECOLOGY. 

entirely the support of the vaginal wall. There may be pro- 
lapse of the vaginal walls, either anterior or posterior, due to 
laxness of the mucous membrane itself. Emmet's operation 
can be done in case the perineal operation is not indicated. 
Where the operation on the perineum is not sufficient to 
restore the vagina to its proper size this operation can be 
done at the same time. The plan is about the same for the 
anterior and the posterior wall. It consists in denuding an 
oval patch in the median line, at the level of the greatest 
relaxation. Smaller patches are now denuded on either side 
of this one, equidistant from it and at the same level. The 
stitches are so introduced as to cause these smaller denuded 
surfaces to be drawn in contact with the large surface, each 
small surface covering half the large one. When they have 
healed a pucker is formed, and the vaginal wall is thickened 
and drawn together thereby. This operation can only suc- 
ceed when the cause has been removed. When this is not 
done the relief is only temporary, as the mucous membrane 
will soon yield to the forces acting upon it, causing a return 
of the trouble in the same manner as it originally came. 

The operation described for the relief of vaginal prolapse 
is mentioned here simply as one of the best plans devised for 
correction of this condition. It shows clearly what such an 
operation should aim to do, and the most successful means 
of attaining that end. Many other methods have been sug- 
gested and employed with satisfactory results, but the same 
idea runs through them all. If done in conjunction with 
perineorrhaphy it will often be convenient to carry the 
denudation up on the posterior wall and make the line of 
sutures continuous. 



UTERINE DISPLACEMENTS. 291 

The constitutional treatment requires the taking of tonics, 
especially nux vomica or strychnia, the general surroundings 
necessary to improve the general health, and especially to 
build up relaxed tissues. These remedies are especially indi- 
cated in cases of prolapsus where there is anaemia or a gen- 
eral flabby condition of the tissues over the body. They 
should be accompanied by baths, massage, faradism, and 
every other means indicated to restore muscular tone. 

G-eneral treatment will do most in those cases where the 
organs can be returned to their proper position and retained 
by tampons, astringents, etc., as has already been described. 
Where there is general plethora and constipation, remedies 
for the digestion and liver are needed. As a rule, nothing 
better than the rhubarb, ipecac, and soda mixture given 
elsewhere can be used for these women. If the constipation 
is extreme, about a half-drachm of the sulphate of magnesia 
may be added to each dose for a time. 



CHAPTER XII. 

SALPINGITIS AND PERI-SALPINGITIS. 

Salpingitis. — The diseases of the Fallopian tubes are rarely 
idiopathic. They are usually sequelae of diseased condition 
elsewhere in the genital canal. The organ whose involve- 
ment in disease process is most frequently followed by tubal 
disease is the uterus. The tubal disease is usually inflamma- 
tory and always a result of infection by germs. The uterine 
diseases causing inflammation of the tubes are the various 
forms of metritis, those resulting from gonorrhoea, badly 
managed labor, and abortion being most common. The 
manner in which the infection reaches the tubes has already 
been indicated, as has the fact that both appendages are more 
apt to be involved as a sequel of gonorrhoea, while the post- 
puerperal cases are usually followed by infection of one ap- 
pendage only. 

Varieties. — The inflammation in the tubes is either catar- 
rhal or purulent. The latter form must not be confused with 
pyo-salpinx, which is a very different condition. Gonorrhoea! 
salpingitis is usually purulent, and may terminate in a pyo- 
salpinx. The symptoms of the two forms do not differ ma- 
terially from each other except in the character of the dis- 
charge from the uterus. This discharge is of course modified 

by anything given off by the uterine walls. The discharge is 

292 



SALPINGITIS AND PERI-SALPINGITIS. 293 

thick in consistency and contains pus when the salpingitis is 
purulent. When a catarrhal salpingitis exists the discharge 
may be transparent and is frequently stained with blood. 
The catarrhal inflammation is more frequently followed by a 
complete cure than the purulent form. The. symptoms are 
generally milder when no pus is present in the tubes. 

In purulent salpingitis there is generally an occlusion of 
the ostium abdominale, but the uterine ends of the tubes are 
patulous. The pus has free access to the cavity of the uterus, 
and a more or less constant stream passes from the tube. 
When there is also occlusion of the ostium uterinum a cyst 
is formed and a pyo-salpinx is the result. Gonococci may be 
found in the pus from a salpingitis of gonorrheal origin, but 
inability to find them is not evidence that the infection is 
not gonorrhoea! 

Acute Salpingitis is a result of an acute gonorrhoea! infec- 
tion of the uterus, spreading rapidly to the appendages. It 
may extend to the pelvic peritoneum and thence to the gen- 
eral cavity, causing all the symptoms of a general peritonitis. 
It usually subsides in a few days, and leaves a chronic salpin- 
gitis and ovaritis. 

The Symptoms of acute salpingitis are those of acute in- 
flammation elsewhere in the pelvis. There is local pain and 
tenderness, usually preceded by one or more chills. The 
fever following the chill may exceed 104° F. and lasts for 
several days. The local temperature in the vagina is higher 
than that of the general body temperature. There is leucor- 
rhoea present in most -cases, though this discharge may be 
suspended while the symptoms of general infection are most 
pronounced. When this is the case the temperature falls 



294 MODERN GYNECOLOGY. 

immediately after the discharge returns. The infection 
from puerperal causes acts in the same manner, except 
that it is preceded by the puerperal condition with its 
symptoms. 

The Treatment of acute salpingitis does not differ from 
that of acute metritis. Rest in bed, saline purgatives, and 
douches are essential, and fluid diet is necessary. 

Chronic Salpingitis is much more frequently met with. 
It rarely ends in spontaneous recovery ; in fact, only the 
most radical measures result in a cure, and then at the ex- 
pense of mutilation. The symptoms of salpingitis are those 
of chronic pelvic inflammation. Ovaritis, when a complica- 
tion, will add its symptoms. 

Symptoms. — There is pain, which is frequently neuralgic in 
character and may be intermittent in its severity. It is 
usually located at the sides of the uterus and in the inguinal 
regions. The pain is usually worse at the menstrual period, 
though exceptional cases are met who feel better when men- 
struating than at any other time. Menorrhagia is almost 
always found, and irregularity in the time of the menstrual 
flow is frequent. Leucorrhoea is always present. It is usu- 
ally copious, and may be periodic in quantity. The examin- 
ing finger will detect the symptoms of the metritis or other 
complicating conditions present. The tube-like sensation the 
enlarged appendage produces is unmistakable. The tube is 
large and tender on pressure, and is usually lower in the 
pelvis than its normal position. This condition is difficult 
to make out in some cases when much inflammation is pres- 
ent around the tube. At times the tube is tortuous and much 
enlarged. When the cervix is inspected through a speculum 



SALPINGITIS AND PERI-SALPINGITIS. 295 

the character of the discharge is shown by the plug in the 
cervical canal. 

Treatment. — To treat chronic salpingitis the utmost patience 
on the part of the physician is required. These cases go on 
improving for a time, and then, imagining they are well, they 
cease to come for treatment. The result is a suspension of 
care-taking and a, consequent return of the symptoms. This 
recurrence may be a new attack brought on by over-exertion, 
or it may be only an increase of the discomfort caused by 
the old condition. 

The treatment of chronic salpingitis is almost entirely local. 
The only internal medication is, that when there is much 
congestion of the uterus a free catharsis may be indicated. 
The first element in the local treatment is directed to the 
condition of the vagina and uterus. The most scrupulous 
asepsis must be maintained in these parts. For keeping the 
vagina in this condition frequent douches must be taken. The 
use of borax, sodium chloride, or other drugs in the douches 
may be indicated. The indications for these substances and 
the manner of using them has already been outlined in de- 
scribing the treatment of vaginitis. 

The cervix must be kept free from plugs of mucus, and 
patulous, and, if it can be done without danger of exciting 
acute inflammation, the endometrium should be treated. The 
treatment of the surrounding inflammation in the pelvic 
peritoneum will be described under that heading. The treat- 
ment directed to the condition of the tubes themselves claims 
attention. While the communication between them and the 
uterus is free the pus- can make its exit from the tubes into 
the cavity of that organ. Efforts should be made to promote 



296 MODERN GYNECOLOGY. 

this exit by every means available. If the tubes have become 
depressed in the middle, tampons can be so applied as to 
straighten them by raising* the displaced portion. If they 
are displaced effort can be made to gradually restore them. 
Both of these things can only be done when the organs are 
free from surrounding inflammation so as to leave them 
freely movable. 

When the tubes have been surrounded with exudation so 
that they are not movable little can be done for their replace- 
ment. The methods elsewhere advised for the absorption of 
the adhesions can be tried. All manipulations must take 
into consideration that the tubes are within the adhesions. 
The tube wall may be so thinned by the pressure from 
within that rupture may result from slight tension. If 
the tube is bound down in a position accessible from the 
vagina, it may be advisable to puncture the tube through 
the vaginal wall and drain it in that way. This method is 
more likely to be required for pyo-salpinx, and will be men- 
tioned again. 

Drainage through the cervix must be maintained, and at 
times the introduction of a drain in the canal is required. 
The gold wire drain of Dr. Outerbridge is the best instru- 
ment for this purpose (see Fig. 50, page 217). When the 
tubes show a tendency to close at their uterine ends some- 
thing can, at times, be done to prevent complete occlusion. 
If there is entire absence of surrounding inflammation bene- 
fit may be obtained from' these efforts. Curettement for this 
purpose is frequently done. The most rigid antisepsis must 
be observed in doing the operation. To obtain the benefit 
desired the part of the endometrium around each ostium 



SALPINGITIS AND PERI-SALPINGITIS. 297 

uterinum must be gone over a number of times. The dull 
curette is used. The endometrium must have the usual 
painting after the scraping, and an open cervical canal must 
be maintained. 

Some surgeons have passed a sound through the opening 
directly into the Fallopian tube to secure drainage. This 
can be done, but it is not devoid of danger and it frequently 
requires much time to find the opening. A small catheter 
has been introduced in this way and the tube emptied. After 
this is done a washing of the tube could be done and reme- 
dies introduced into its cavity. The care about rupture and 
forcing open the sealed abdominal end must not be forgotten. 
The mucous membrane lining a tube in which a purulent 
inflammation has existed becomes a pus-forming membrane. 
Pressure or caustics are required to stop the formation of 
pus, which process will go on indefinitely unless the mem- 
brane is treated or the tube removed. If some tincture of 
iodine can be injected into a tube after it has been drained 
and washed out, there is some chance of preventing the further 
formation of the pus. Strong solutions of nitrate of silver will 
act in the same way and may give even better results than 
the iodine. The dangers and difficulties of these efforts at a 
radical cure are considerable, but the only complete cure by 
other methods is by removal. A laparotomy is also danger- 
ous, and its dangers are much enhanced by the extent of 
adhesions in which these tubes are usually imbedded. The 
possibility of getting into the tube through the uterus is 
beyond dispute. I have, frequently had a curette enter a 
dilated tube when doing a curettement, and have never seen 
any unfavorable symptoms result from it. Of course care 



298 MODERN GYNECOLOGY. 

was taken not to push it through into the abdominal cavity. 
None of these things should be attempted by inexperienced 
men. 

Applications to the vagina kept up for a long time will be 
most satisfactory to the general practitioner. The patient 
can come to the office once every five days and receive an 
application of iodine and creosote to the vagina. This is 
followed by the packing with tampons. In the intervals she 
uses the hot- water douches and avoids over-exertion and is 
tolerably comfortable. When she knows that the alterna- 
tive is a serious operation the average woman will prefer 
treatment even for many months. 

Peri=salpingitis. — Inflammation of the Fallopian tubes 
and that of the peritoneum immediately around them are so 
intimately associated in their symptoms and treatment that 
no effort at their separate consideration will be attempted. 
The general description of pelvic peritonitis will exhaust 
those parts of the subject not included in the consideration 
of salpingitis. It is doubtful if a peri-salpingitis ever exists 
without a preceding salpingitis. This clinical picture is not 
materially different, and no effort at minute pathology is 
required. When the inflammation around the tube is exten- 
sive enough to cause symptoms of itself it becomes to all 
intents and purposes a pelvic peritonitis, the description of 
which will follow. 

Pyo=salpinx. — Of pyo-salpinx little need be said. The 
tube is sealed at both ends, forming a cyst. When this cyst 
contains clear watery fluid it is called a hydro-salpinx, and 
when blood is within it it is a haemato-salpinx. These con- 
ditions do not differ materially in the symptoms produced 



SALPINGITIS AND PERI-SALPLNGITIS. 299 

from pyo-salpinx. They are not common, and will not re- 
quire further attention. 

SyuqrfoHis. — In pyo-salpinx, the tube being closed, there is 
no purulent discharge. There may be leucorrhcea due to 
causes existing in the other tube, in the uterus, at the cervix, 
or in the vagina. As a rule, only one tube is occluded. The 
symptoms do not differ from those of chronic salpingitis. 
The examination enables the distinction to be made. A 
rounded mass will usually be felt at one side of the uterus. 
It may be as large as a man's fist. If not too much obscured 
uy the thickened peritoneum fluctuation can be made out. A 
crease can usually be made out between the uterus and the 
tumor. The mass feels not unlike the fundus might feel if 
enlarged and misplaced. The fundus can be found elsewhere 
in the pelvis, either with the examining touch or a sound. 
The conditions most liable to be confused with pyo-salpinx 
are other kinds of enlargements of the tube, ovarian cyst, and 
hematocele. The enlargements of the tube may be due to 
the presence of blood or other fluid in a sealed-up tube, or 
a tubal pregnancy. The latter condition can usually be dis- 
tinguished by the presence of some of the rational symptoms 
of this condition. If there is doubt, a removal of some of 
the material from within the uterus may clear up the diag- 
nosis. It is believed that decidua can always be found in the 
uterus when extra-uterine gestation exists. A microscopic 
examination of material from the endometrium may find this. 
Its presence is diagnostic, while its absence is not positive evi- 
dence that a pregnancy does not exist in the tube. Hemato- 
salpinx will usually have a history of suppressed hemorrhage, 
or some symptoms by which it can be distinguished, 



300 MODERN GYNECOLOGY. 

The Treatment of pyo-salpinx is essentially surgical. When 
the tumor is adherent to the vaginal roof and separated 
from the general peritoneal cavity it may be evacuated 
through the vagina. When not accessible through the vagina 
the only rational treatment is removal by laparotomy. The 
"dangers of rupture are considerable, and delay should be 
advised against. 

Pelvic Peritonitis and Pelvic Cellulitis. — These condi- 
tions can well be considered together, as they are so fre- 
quently associated, the latter rarely, if ever, being found 
except in conjunction with the former or as an immediate 
sequence of it. The question of the existence of a true 
pelvic cellulitis will not be discussed here. The fact that the 
specialists in the profession are divided into almost equal 
parts proves one. thing in regard to the claims of each. It 
proves that the conditions are so closely allied in symptoms 
and pathology that they are rarely differentiated clinically. 
This being the case, they will be described under one head 
in this place. This seems all the more appropriate as the 
treatment is the same for each. 

The Pelvic Peritoneum. — By pelvic peritonitis is meant an 
inflammation of that portion of the peritoneum in the pelvis. 
A brief mention of its anatomy will make this subject clearer. 
The peritoneum comes down along the interior of the abdo- 
men and passes over the upper part of the bladder, covering 
that viscus from a point slightly down its anterior wall back- 
ward. Its folds dip behind the bladder, covering a large 
part of its posterior wall. This membrane then rises along 
the anterior of the uterus. This depression or pocket be- 
tween the bladder and uterus is in intimate relation with the 



SALPINGITIS AND PERI-SALPIXGITIS. 301 

anterior wall of the vagina, high np in front of the cervix 
uteri. The peritoneum passes upward along the anterior 
uterine wall, covering the fundus uteri, to which it is closely 
adherent, then, dipping behind this organ, it follows its con- 
tour along its posterior wall to a point near the level of the 
internal os. From this point the peritoneum again rises 
along the rectum and posterior walls of the pelvis, passing 
upward into the abdominal cavity. This depression between 
the uterus and the rectum is the cul-de-sac of Douglas, and 
can be felt by the examining finger behind the cervix in the 
highest point of the vagina. 

The fold of peritoneum covering the fundus of the uterus ex- 
tends on either side of that organ, remaining closely adherent 
to its lateral walls. It is here perforated by the Fallopian tube 
on each side. The fold of peritoneum passes over, forming the 
upper edge of the broad ligament, and then extends almost 
vertically down to the bottom of Douglas' pouch. The tubes 
and ovaries are behind this last-mentioned part and attached 
to it, the external end of this sheet of peritoneum being at- 
tached to the bony pelvis, its inner end being attached to the 
uterus. This broad ligament is thus a double fold with the 
uterine appendages behind it. It aids the other ligaments in 
supporting the uterus in its upright position in the pelvis. 

The folds of peritoneum depressed between the bladder 
and uterus in front and those between the uterus and rectum 
behind form the two pockets where pelvic peritonitis is found. 
The inflammatory condition may extend upward over the 
fundus higher and involve the general peritoneal cavity in a 
general peritonitis ; but it usually has its beginning in one 
of these pockets. 



302 MODERN GYNECOLOGY. 

The cul-de-sac of Douglas is usually the point first in- 
volved in a pelvic inflammation. The fact that these in- 
flammations are always the result of infection from without 
accounts for this result, because the infection is often carried 
in through the tubes, and these are suspended just above this 
cul-de-sac. 

The Causes of pelvic peritonitis are many. It is frequently 
due to septic infection from the uterus. In the puerperal 
state, when that organ becomes infected the inflammation 
can reach the peritoneum in several ways. It may travel 
up along the Fallopian tubes and out of their fimbriated ex- 
tremities, involving the peritoneum ; it may travel along the 
lymphatics and reach the peritoneum ; it may travel through 
the veins as a septic phlebitis and involve the peritoneum ; 
and it may travel by juxtaposition of tissue through the 
uterine walls, involving those folds of peritoneum in imme- 
diate contact with the uterine fundus, and thence spread 
along the peritoneal substance, involving more or less of that 
membrane. 

The puerperal state causing it may be from an abortion or 
from a delivery at term. More cases of pelvic peritonitis 
are met with following abortion and miscarriage than deliv- 
ery at term. The general manner in which it comes about 
is by causing a metritis and subinvolution, and the peritoneal 
involvement is a direct sequence of the inflammation of the 
uterus. 

The metritis may come from other than puerperal causes. 
The route of the infection is the same, though its results 
may differ, due to the infecting substance. The peritonitis 
may follow immediately after the infection, but more fre- 



SALPINGITIS AND PERI-SALPINGITIS. 303 

quently the metritis exists for a time before the peritoneum 
is involved. 

The most frequent cause of pelvic peritonitis after the 
causes following pregnancy is gonorrhoeal infection. A 
gonorrheal vaginitis becomes a cervical metritis, a corporeal 
metritis, a salpingitis, and then, either by contiguity of tissue 
or from leakage from the outer ends of the tubes, a pelvic . 
peritonitis. Any exciting cause may set up an acute salpin- 
gitis in tubes full of gonorrhoeal pus and result in an inflam- 
mation of the pelvic peritoneum. Other causes of pelvic 
peritonitis are cold, especially at the time of or immediately 
before the menstrual flow, falls or other injuries, strain from 
lifting or overwork, injury from coitus or other cause, in- 
juries to the cervix, as laceration, and drugs. The taking of 
drugs to bring on the menstrual flow is frequently resorted 
to by married women who wish to avoid pregnancy, and 
pelvic peritonitis is one of the most serious of the conse- 
quences that follow this dangerous custom. Many women 
are to-day suffering and enduring much inconvenience, re- 
quiring operations and treatment to restore them to even an 
approximation to a healthy condition, as a result of efforts 
in this and other ways to avoid pregnancy and its incon- 
veniences. The mechanical means often used to induce abor- 
.tion are responsible for many cases of peritonitis resulting 
from septic poisoning at the cervix, which is usually injured 
by such efforts, and many deaths are due to this cause alone. 
Another cause of pelvic peritonitis is operative procedures to 
the cervix and uterus. Cases are on record of fatal perito- 
nitis resulting from passing a uterine sound. Inflammation 
may be lighted up by the manipulation necessary to repair a 



304 MODERN GYNECOLOGY. 

uterine cervix, or it may follow curettement. In these cases 
a previous inflammation usually exists, leaving adhesions or 
chronic peritonitis, which is lighted up by the operation. 

The Symptoms of pelvic peritonitis may be indefinite, but 
they are usually sufficient to cause an investigation of the 
condition of the pelvic organs. There is frequently a history 
of a cause. She will confess to getting up too soon after a 
confinement, or to a miscarriage where no physician was 
seen. There may be only a history of a menstruation delayed 
a week or two " over time, 1 ' followed by a very profuse flow 
with much pain and clots of blood. This will indicate an 
abortion where the fetus was so small that its exit was 
not noted. There may be a history of a very profuse leucor- 
rhcea of yellowish color and creamy consistency, accompanied 
by frequent micturition and dysuria, indicating an attack 
of gonorrhoea. The patient will usually be ignorant of the 
cause of this attack, and frequently she has no suspicion of 
its nature. Acute pelvic peritonitis may follow the exciting 
cause immediately, when the history is easy to trace. Fre- 
quently there is an interval of gradually getting worse, until 
some accident lights up the chronic condition and is looked 
upon as the cause of all the mischief, when its real cause oc- 
curred, it may be, years back. 

In either case the symptoms of an acute attack are the 
same. There is the usual condition found with acute in- 
flammations in the pelvis — fever, which may be as high as 
104° F. or more. The pulse goes up with the fever, unless 
dangerous weakness sets in, when it will sink to the normal 
or below and be very feeble. Nausea and vomiting are fre- 
quent. There may be no other constitutional symptoms. 



SALPINGITIS AND PERI-SALPINGITIS. 305 

There usually is pelvic pain, aggravated by motion of the 
limbs or pelvis, and by defecation, burning in the vagina, 
with or without leucorrhcea, backache, and pains in one or 
both inguinal regions. This last symptom frequently indi- 
cates the side on which the inflammation is most pronounced, 
though both sides may be equally involved. Frequent mic- 
turition is also a frequent symptom, and pain when the 
bladder is full is common. 

Digital Examination of the vagina removes all doubts as to 
the condition. The vagina will feel hot, showing the pres- 
ence of local inflammation, and is usually extremely sensitive. 
The pelvic floor is hard and tender. The least touch against 
the cervix causes pain, and any effort to map out the posi- 
tions of the organs will cause much suffering. It is well in 
these cases not to attempt to learn too much at the first ex- 
amination, as the inflammation may be dangerously aggra- 
vated by rough examining. If the inflammation is due to 
puerperal causes the leucorrhcea is apt to be stained with 
blood and considerable odor is present ; whereas if the cause 
is gonorrhceal the discharges are seldom stained with blood 
and there is no odor of the character caused by retained 
secundines. 

The Treatment of acute pelvic peritonitis is much the same 
as that of a general peritonitis. Like the treatment of the 
latter condition, it has been radically modified within the 
past few years. ' The results obtained warrant the change. 
The treatment is of two kinds, internal and local. The in- 
ternal treatment should be begun with a thorough saline 
purgative. The best drug for this purpose is Epsom salts. 
This should be given in the form of a saturated solution in 



306 MODERN GYNECOLOGY. 

small doses frequently repeated. It is best to give from one 
to four teaspoonfuls every half -hour until a thorough purg- 
ing is obtained. If there is vomiting and the sulphate of 
magnesium cannot be retained, opium or morphine sulphate 
by hypodermic injection must be used in sufficient quantity 
to control the vomiting. If enough morphine is required to 
get its narcotic effects, it should be followed by the magnesia 
in one large dose, an ounce or more, as soon as the stomach 
will retain it. The purgative action will then commence as 
soon as the morphine effect begins to pass off. When treated 
in this way the vomiting rarely recurs, and the purging is 
followed by a fall of temperature and a profuse perspiration 
and usually by sleep. She will awake from this sleep weak, 
but free from pain and feA r er, and convalescing. 

If there be much pain a small hypodermic injection of 
morphine should precede the purgative. An eighth of a 
grain or less will usually make her quite comfortable and 
will not give any of the constipating effects of the opium. 
After the purge has acted, rest and perfect quiet are of the 
utmost importance. Little medicine is needed for the next 
few hours. If the fever goes up again the purge must be 
repeated, or calomel in a dose of from ten to twenty grains 
may be substituted, to be repeated in four or five hours if 
needed. 

The manner in which the sulphate of magnesium acts has 
been hinted at elsewhere. The solution causes a discharge 
of the fluids from the intestinal glands into the gut. The 
intestine is thus filled with an alkaline solution. On its outer 
side is the seat of the inflammation. Between them are one 
or more layers of animal membrane. These are the condi- 



SALPINGITIS AND PERI-SALPINGITIS. 307 

tions most favorable to osmosis, and the result is a flow from 
the tissues to the interior of the intestinal canal. The deple- 
tion of the local tissues acts on the same principle as a local 
plebotom}\ The main difference is that in bleeding all the 
constituents of the blood are removed, while the purging 
only removes the fluids, leaving most of the nourishing ele- 
ments yet in the circulation. One or more such local depict- 
ings may be required to cause the acute stage of the inflam- 
mation to subside. 

After the use of saline cathartics care must be taken to 
prevent the alimentary canal from being closed again. The 
free evacuation must be kept up. The rhubarb and ipecac 
mixture given on page 224 will usually be sufficient. A tea- 
spoonful is given every two or three hours as may be needed. 

If the magnesium sulphate solution causes much griping 
or there is much discomfort from gas in the bowels it may 
be relieved by sedatives. 

Spr. lavend. comp § j 

Aq. anise q. s. ad. | iv 

M. Sig. 3 ij to | j every three hours. 

The above solution will soon quiet the bowels without in- 
terfering with the purgative. If the gas causes a general 
tympanitis over the colon and the patient is unable to expel 
it, a long rubber tube can be passed high into the colon 
through which the gas can find an exit. The patient will 
be much relieved by this device. 

This treatment must be accompanied by the most perfect 
quiet and absolute rest in bed. All dejections from the 



308 MODERN GYNECOLOGY. 

bowels or bladder must be received in a bed-pan. The pa- 
tient should be moved as little as is possible. In putting the 
bed-pan under her she must not raise herself but must be 
lifted by the nurse. 

The food given must be guarded with scrupulous care. 
Milk is not a safe food during the first few days. Its tend- 
ency to curdle makes it dangerous at times, as the bowels 
may be seriously clogged up by it. Toast and bread in any 
form are bad. The diet safest to use is composed of thin 
soups and broths containing no milk or starchy matter. The 
basis of these should be meat, and they should be strained 
so as to contain no solid particles. 

If any tendency to continuous febrile action exists, five 
grains of the sulphate of quinine given three times a day will 
be of benefit. Aside from this, drugs are rarely indicated. 

The local treatment of acute pelvic peritonitis is important. 
The vagina must be douched three or four times in every 
twenty-four hours. These douches should be given with the 
utmost gentleness and the force of the stream should be as 
little as possible. The temperature of the water should be 
from 105° to 110° F., and about a gallon should be used at 
each time. In some cases the douche cannot be used for 
the first few da} r s, as the parts are too tender to bear any 
manipulation. 

Abscess. — Acute pelvic peritonitis may result in abscess. 
The abscess may either go on to suppuration and be expelled 
in various directions, or it may end in resolution. The most 
favorable result is when it ruptures into the vagina. The 
bladder, the rectum, the intestine, or the general peritoneal 
cavity may all be invaded by the pus from a ruptured ab- 



SALPINGITIS AND PERI-SALPINGITIS. 309 

scess. When the abscess can be felt through the roof of the 
vagina and hematocele has been excluded the correct treat- 
ment is puncture and evacuation. This should be followed 
by thorough cleansing and tight packing. The packing 
should be frequently changed, the cavity being washed out 
when the packing is out. The abscess may result in resolu- 
tion, but it is dangerous to trust to getting such a result. 
The golden rule of surgery should receive no exception when 
the pelvis is involved. Pus should always be removed when 
found. 

Chronic Pelvic Peritonitis. — Acute pelvic peritonitis may 
terminate in recovery and complete resolution of the inflam- 
matory process. More generally the result is in a chronic 
pelvic peritonitis. The course of chronic pelvic inflamma- 
tion is indefinite. Usually there is a number of attacks of a 
more or less acute form. These attacks may be brought on 
by violence of any kiud, by colds, by a fresh infection of 
germs from an abortion, or by other causes. 

These attacks last for a variable length of time and then 
subside. They usually add something to the amount of 
exudated material in the pockets of the pelvic peritoneum. 
The "adhesions" are the most important sequel of the in- 
flammation. They are bands of plastic lymph which become 
organized and bind the pelvic organs together. The quan- 
tity may be so great that all these organs are glued together 
in one solid mass, filling the entire pelvis. If there is uterine 
deviation the organ is fixed in that position. If the ovaries 
or tubes are prolapsed they are imbedded in the adhesions 
and held permanently in their abnormal position. 

Tlie Symptoms of chronic pelvic peritonitis are many of 



310 MODERN GYNECOLOGY. 

them reflex. They depend upon the extent to which the 
pelvic peritoneum is involved. If there is only a small 
amount of inflammatory products in Douglas' cul-de-sac, they 
may be slight or none at all. If the involvement is exten- 
sive the suffering caused may keep the patient in bed. 

Pains and heaviness in the pelvis with tenderness over the 
lower abdomen and dragging pains in the back are usually 
present. When found, these symptoms are all made worse 
by remaining too long standing, by walking, or by any 
movements involving the muscles of the abdominal walls or 
the muscles from the thighs that enter the pelvis. The latter 
muscles may be so interfered with as to cause lameness and 
even to prevent the use of the thighs. The passage of 
masses of feces through the rectum causes pain. Pain is 
also present when the bladder is full. Coition or examina- 
tion of the vagina is painful, and douches may cause extreme 
suffering. 

The reflex symptoms are of the class already described 
under the head of " uterine syndroma " in the chapter on 
metritis. The nausea is apt to be annoying, and vomiting 
is common. Indigestion, flatus, and constipation are gener- 
ally present. Pains in the top of the head and at the back 
of the neck are usual and cause the patient much dis- 
comfort. 

Examination is frequently made with difficulty because of 
the tenderness around the uterus. The least motion of the 
cervix causes complaint, and a bimanual examination is im- 
possible in most cases. The peculiar boardlike impression 
the finger receives from the pelvic floor is characteristic. It 
is, in many cases, impossible to indent the vaginal roof. The 



SALPINGITIS AND PERI-SALPINGITIS. 311 

finger cannot be pushed up by the side of the cervix to any 
extent, and the position of the uterus cannot be made out. 

These are the cases in which the use of a sound can do so 
much harm. The chronic inflammation can easily be lighted 
up into an acute form, and may even spread to the general 
peritoneal cavity. 

Treatment of these cases of chronic pelvic peritonitis is 
tedious. They do not get well rapidly, yet the amount of 
good that can be accomplished by properly directed efforts is 
at times surprising. The greatest caution is not to attempt 
too much at once. All applications must be made carefully, 
and for a time at least must be made to the vagina only. 
The liquor Monsel is a most important remedy. The amount 
used must be regulated by the results obtained. If the mu- 
cous membrane will stand it the applications can be made 
every five clays. If much irritation is caused they must be 
made further apart. If any erosion or laceration is present 
at the cervix a painting with the iodine and creosote mixture 
will be of benefit. It may be introduced into the cervix if 
this can be done without too much effort. 

The applications to the vagina should be followed by a 
tampon. Here, again, caution must be observed at the first 
few treatments until the endurance of the condition is learned. 
The contraction caused by the iron solution is so great that 
a very small tampon may cause much pain. The contractions 
will be more if glycerine is used. Usually it is better not to 
use anything on the tampon during the first stages of the 
treatment. The tampon becomes saturated with the iron 
solution and secures to the mucous membrane a prolonged 
contact. The result from the medicine is thus increased. 



312 MODERN GYNECOLOGY. 

After the tenderness has been removed and the dangers of 
acute exacerbation have passed, it may be advisable to pack 
the vagina full of tampons in order to secure the effects of 
pressure on the adhesions to aid in their attenuation. The 
methods for the further treatment of these adhesions is de- 
scribed in the chapter on uterine deviations. 

Douches are an important factor in the treatment of 
chronic pelvic peritonitis. They must be hot, prolonged, and 
at low pressure, and not used in a way to produce pain. One 
or two gallons three times a day is usually the best quantity 
to use. A temperature of 110° F. can usually be well borne. 

Rest in bed for a few weeks at first may be necessary, but 
in many cases only care in going about is required. 

Internal medication is of benefit in many cases. The 
iodide of potassium is frequently used, and the bichloride of 
mercury can be given with it in the form of " mixed treat- 
ment." 

$ 

Hydrarg. chlorid. cor gr. ss 

Potass, iodid 3 ij 

Syr. sarsaparil. comp § j 

Aqua q. s. ad § iv 

M. Sig. 3 j after each meal in water or milk. 

The above gives five grains of the iodide and one sixtieth 
of a grain of the bichloride to each teaspoonful. If more is 
needed a dose of two teaspoonfuls can be used. 

Bromides and remedies for the alimentary canal can be 
used as indicated. The chief element is not to do too much 
manipulating in the pelvis, and to take plenty of time. Six 
months or a year may be needed to effect a cure, 



CHAPTER XIII. 

DISEASES OF THE OVARIES. 

The various diseased conditions of the ovaries are so inti- 
mately associated with other forms of disease in the pelvis, 
external to the litems, that it is a matter of considerable 
difficulty to make the differential diagnosis, and at times it 
is even impossible to do so ; nevertheless a distinct ovarian 
pathology exists, and its appreciation should be attempted. 
The conditions that are difficult to distinguish from ovarian 
involvement are diseases of the Fallopian tubes, neoplasms 
in and around the broad ligaments, and pelvic peritonitis, 
either with or without abscess or pelvic hamiatocele. The 
most confusing of these are salpingitis and peri-salpingitis, 
and as the treatment for both of these does not differ mate- 
rially from that of ovarian inflammation it has been taught 
that their distinction is not material to the practitioner. This 
does not seem to be sufficient grounds for describing diseases 
of the ovaries and tubes together, hence a chapter is devoted 
to each. 

Congestion of the Ovaries. — There is a group of symp- 
toms, varying somewhat according to different observers, but 
by all attributed to the ovaries, that cannot be called an 
ovaritis of either acute or chronic form. It has been called 
hyperemia by some, congestion, irritability, or neuralgia by 

m 



314 MODERN GYNECOLOGY. 

others, yet none of these terms completely conveys what the 
condition is. The limits of this disease become narrower as 
knowledge of the true pathology of the ovaries increases, and 
will no doubt be even more reduced by further observation. 

Causes. — The symptoms of this condition indicate that it 
is caused by undue excitement of the functional activities of 
the ovaries. Young girls who live in unhealthy moral sur- 
roundings exciting their passions, which are ungratified by 
sexual connection, suffer from it. It is also frequent in en- 
gaged women, due to caresses, and in many cases they are 
entirely unconscious of the cause of their suffering. The 
natural function of sexuality is stimulated and congestion 
ensues. The reading of sensational novels is another fruit- 
ful cause of this condition. It is also found in young widows 
at times. Sedentary habits, excessive applications to study, 
and constipation are also causes of this condition. " Inter- 
menstrual pain " belongs to this class of ovarian diseases. 

The condition supposed to exist is indicated by the names 
given to the disease. There is believed to be too much blood 
in and around the ovary, producing a congestion and result- 
ing irritation, and at times pain. This congestion is relieved 
by the menstrual flow, and accounts for .the frequent absence 
of symptoms at or immediately following menstruation, 
especially if the flow is profuse. It is also relieved by any 
other depleting condition, and marriage frequently cures it. 
Pregnancy causes a suspension of the ovarian function and 
cures the malady by rest. 

In married women excessive coitus is occasionally a cause 
of ovarian congestion. When due to this cause, sterility due 
to the same excess is apt to exist, 



DISEASES OF THE OVARIES. 315 

The Symptoms of ovarian congestion are indefinite, bnt 
chiefly of the character called " nervous." The patients are 
fretful, irritable, and easily excited. There may be irritabil- 
ity of the bladder with frequent micturition. If not relieved 
by abundant menstruation she may become anaemic and ac- 
quire nervous debility, hysteria, or other diseased conditions 
of the nervous system. If the surroundings are favorable 
she may resort to onanism. 

Examination of the pelvis may reveal absolutely' no evi- 
dence except the irritability in which the whole organism par- 
ticipates, but usually there is tenderness in the region of one 
or both ovaries. If they can be made out at all the ovaries 
are in most cases somewhat enlarged. Tenderness over the 
ovary in the inguinal region is a common symptom. 

It is common to find an anteflexion of the uterus with these 
cases, usually of congenital origin and accompanied by ste- 
nosis. In these cases it may well be that the uterine trouble 
acted, at least in part, as an etiological factor to the ovarian 
disease. 

The Treatment of congestion of the ovaries must begin 
with a removal of the causes. The engaged young woman 
had best get married, the novel reading must be suspended, 
the overwork at study or sedentary occupation must give 
way to rest, the crowded city had best be left for freer cus- 
toms and better air in the country. Pure air, healthful ex- 
ercises, and proper moral atmosphere must be secured. Sea 
baths, cold bathing, with friction and massage, may be of 
assistance, but are not so important. The nervous irrita- 
bility must be controlled by bromides, in the form of the 
bromide of sodium, either with other remedies or alone, and 



316 MODERN GYNECOLOGY. 

must be given in sufficient amount to control the symptoms ; 
from fifteen to twenty grains three or four times each day 
or oftener may be required. Its use must be continued a 
long time, though a single dose each night may be sufficient. 
The stomach must be protected from the bromide salts by 
plenty of water administered with it. 

Tonics must be taken at the same time, nux vomica being 
the best. This can be taken alone, or with iron if anaemia 
be present. Ergot will relieve the congestion and lessen the 
irritability by diminishing the amount of blood in the pelvis. 
The constipation so frequently present must be relieved and 
its recurrence prevented. Cascara in some form will often 
be efficient for this purpose, or the following made into a 
pill or capsule may act better : 

Extr. nuc. vomic gr. iv 

Extr. belladonna gr. iij 

Extr. colcynth. comp. 3 j 

Aloin gr. v 

M. Ft. pil. No. xxx. Sig. From one to three pills before 
retiring. 

In cases of women who have been married, frequent irri- 
gation of the vagina with a gallon or more of hot water at a 
temperature about 110° F. will often relieve the congestion 
and allay the symptoms. When due to excess in married 
women, separation of a few months from the husband will 
frequently effect a cure without other treatment, pregnancy 
often following the return to her home and bed. 

Ovaritis. — Inflammation of the ovaries is either acute or 
chronic. 



DISEASES OF THE OVARIES. 317 

Acute Ovaritis may be either of gonorrhoea! or puerperal 
origin. When the infection is gonorrhoea! both ovaries are 
liable to be involved, while inflammation due to puerperal 
infection is frequently confined to one ovary. Other causes 
of infection are rare, but some authorities claim to have seen 
them, the germs entering the organism in a manner similar 
to the entrance of the poisons of the eruptive fevers. 

The united opinion of all modern observers is that ovaritis 
can only exist with the invasion of the ovary by infecting 
germs, the manner of their conveyance being usually by 
continuity of tissue through the uterus and Fallopian tubes, 
although occasionally they may gain an entrance through 
the lymphatics, the veins, or directly through the substance 
of the uterine walls and adjacent tissues. When the disease 
is carried by any channel but the natural one the pelvic 
peritoneum is, as a rule, first involved, the inflammation of 
the ovaries being a complication of the peri-metritis and 
peri-salpingitis. 

Acute ovaritis frequently occurs as an exacerbation of a 
chronic inflammation, and a number of these recurrent 
attacks may be seen in the same patient, very slight provo- 
cation being required to start them. Acute ovaritis is usually 
complicated by salpingitis or peri-salpingitis, or both, the 
inflammation in the tube being at times confined to the fim- 
briated extremity. It is impossible to tell if there was first 
an ovaritis, a salpingitis, or a pelvic peritonitis in these cases. 

The termination of acute ovaritis is in abscess, which may 
involve the whole organ, forming one large abscess cavity, 
which may rupture into the abdominal cavity, the vagina, 
the rectum, or the bladder j or it may result in resolution 



318 MODERN GYNECOLOGY. 

without abscess or other injury to the ovary, or it may be- 
come a chronic ovaritis. 

The Symptoms of acute ovaritis are those of acute pelvic 
inflammation from any cause. The pain and tenderness are 
usually more circumscribed than in pelvic peritonitis, and 
the so-called nervous symptoms are more apt to predominate. 
There is always more or less of febrile movement, which is 
preceded by a chill or chilly feelings. The local tempera- 
ture is usually considerably higher than that of the general 
body. Nausea and vomiting are more frequently present 
when the ovaries are involved than with other pelvic in- 
flammations. 

Treatment — There are two phases in the consideration of 
treatment for acute oophoritis : the first is the preventive, 
and the other is for the diseased condition itself. 

Prompt attention to gonorrhoea, with a view to restricting 
the disease to the vagina, or curative treatment measures for 
the metritis, will usually prevent the invasion of the ovaries 
by the gonococci ; and like thorough removal of all post- 
puerperal infection from the uterus, as soon as found, will 
prevent the further progress of the germs of this condition. 
Of course it is better yet to avoid puerperal infection at all 
by proper precautions at delivery; but the cases of this 
character frequently reach the gynecologist after this unfort- 
unate event has occurred, and prompt and correct action on 
his part is called for to prevent the spread of the infection 
through the entire genital tract and the invasion of the gen- 
eral system causing a pyaemia. 

Treatment directly for the acute disease in the ovaries is 
not completely satisfactory. The most important thing is 



DISEASES OF THE OVARIES. 319 

perfect rest in bed. The diet should be of a character easily 
assimilated but nourishing, and the pain, if severe, must be 
controlled by morphine. If the stomach is upset the mor- 
phine can be given hypodermatically ; it should be given in 
eighth of a grain doses and not too frequently repeated, so 
as to avoid its constipating effects. A small dose of atropine 
sulphate acts well with the morphine and also has a tendency 
to allay the congestion. The morphine also keeps the stom- 
ach in condition to retain the saline cathartics which recent 
observations have shown to be so important a factor in the 
treatment of acute inflammation in the pelvis, especially 
when tendency to suppuration accompanies the inflammatory 
condition. The production of catharsis is the most important 
part of the treatment of acute pelvic inflammation, and is 
best accomplished with a saturated solution of the sulphate 
of magnesia. The solution is given in doses of two tea- 
spoonfuls every fifteen to thirty minutes until a number of 
copious watery movements from the bowels result. This 
will produce a depletion of the system of its fluids, and act- 
ing by osmosis relieves the congestion, the temperature falls 
immediately, and any tendency to return must.be promptly 
met by a fresh purging. Quinine should be given in the in- 
tervals between the use of the salines. Calomel will act well 
in cases where for any reason the salts cannot be taken, but 
a single dose of the sulphate of morphine will usually be suf- 
ficient to relieve all tendency to be nauseated by the latter, 
and nothing acts so promptly in removing congestion and 
arresting threatened suppuration. 

The use of other remedies indicated is not to be prevented 
by this treatment, especially the local treatment in the form 



320 MODERN GYNECOLOGY. 

of hot douches and hot turpentine stupes to the abdomen! 
Poultices are rarely indicated. 

Chronic Ovaritis. — The inception of chronic ovarian in- 
flammation may be slow ; existing as a chronic inflammation 
from the beginning, it may be due to infection occurring in 
a case of congestion, but this is more liable to cause acute 
ovaritis. The chronic form of inflammation may also result 
from an acute form. 

The inflammatory process may continue indefinitely, or 
may result in hypertrophy due to the formation of fibrous 
tissue, which by its contraction and lessening of the blood- 
supply may eventually cause atrophy and suspension of func- 
tion. These conditions of hypertrophy followed by atrophy 
are sequelae of chronic oophoritis of long standing. 

There is generally inflammation in and around the Fallo- 
pian tubes with the chronic ovaritis, probably preceding it 
in time of its inception and due to a metritis which may still 
remain active. 

Symptoms. — Chronic inflammation of the ovaries is not 
associated with febrile disturbance of the general system. 
The symptoms are distinguished by their tendency to assume 
a " nervous " type, but of a milder form than in acute ova- 
ritis. Mental depression in the form of low spirits and 
attacks of " blues " is a characteristic of this condition ; pains 
in one or both inguinal regions are present, and are fre- 
quently reflected around to the lumbar region or down the 
leg. Reflex headaches, gastric symptoms, and hysteria are 
occasionally present. The pains in the inguinal regions are 
frequently worse for a day or two before the menstrual flow 
begins or during the first day of the flow. In other cases 



DISEASES OP THE OVARIES. 321 

the women are more comfortable at the time of menstruation 
than at any other time. The other symptoms of pelvic in- 
flammation are generally present to a more or less degree, 
many of them no doubt being due to the inflammation exist- 
ing in the pelvic peritoneum, the tubes, or the uterus itself. 

Examination will reveal a more circumscribed spot of ten- 
derness in one or both lateral fornices than in pelvic perito- 
nitis. If the ovary can be made out it can be distinguished 
from a tube by the rounder outline and absence of the tube- 
like sensation communicated to the finger by that organ. If 
displaced into the sac of Douglas immediately behind the 
uterus, the ovary can frequently be made out and its size 
clearly defined. The peculiar nausea produced by pressure 
upon it will help to distinguish the ovary from the tube or 
any other tumor. Rectal examination will frequently give 
more definite information. If a tumor is found which can- 
not clearly be decided about, examination for the ovary else- 
where in the pelvis will often give a clue ; for while inability 
to find an ovary does not prove conclusively its absence, yet 
its discovery higher up is evidence that the suspected tumor 
is not an ovary, cases of a third ovary being too rare to 
deserve consideration. 

Other tumors that might be mistaken for an enlarged 
ovary are fibroma in the broad ligament, cystic tumors in 
the pelvis, pelvic abscess, tubal pregnancy, and fecal masses 
in the rectum. The continuous growth of the fibroma with 
the associated tendency to-hemorrhage will usually establish 
its diagnosis. The fluctuation which can usually be made 
out in cystoma or an abscess will make them evident, while 
the variable size of the oophoritis will distinguish it from 



322 MODERN GYNECOLOGY. 

either tubal gestation or fibroma of the tube or broad liga- 
ment, both of which grow progressively larger, while the 
ovarian tumor often makes considerable changes in size in a 
few days, these changes being closely connected in point of 
time with menstruation and ovulation. 

Hypertrophy of the ovary can usually be felt on bimanual 
examination or by rectal touch, and atrophy is distinguished 
by the discovery of the small ovary and the cessation of its 
functional activity before the patient has reached the age 
when the normal menopause is to be expected. 

The Treatment of chronic ovaritis is either surgical or pal- 
liative ; a perfect cure is not the rule. The general health 
must be improved by tonics, exercise in the open air, if she 
can take it without pain, and attention to the condition of the 
alimentary canal. If much pain exists the -patient should 
maintain a recumbent position and receive massage for the 
exercise of which she is deprived. Counter-irritants to the 
vaginal vault or over the abdomen may prove beneficial and 
should be tried. Tincture of iodine, the actual cautery, or 
blisters can be used for this purpose. 

A most important factor in the treatment of chronic dis- 
ease of the ovaries and tubes is attention to the condition of 
the uterus, disease within this organ being in many cases the 
focus of infection, a breeding-place for germs, from which 
continuous reinfection of the appendages occurs. The endo- 
metrium may need a thorough curettement after dilating the 
cervix, and should be thoroughly mopped off with absorbent 
cotton dipped in very hot water. After rendering the uterus 
thoroughly aseptic, an applicator wrapped in cotton should 
be dipped in a solution of equal parts of glycerine and car- 



DISEASES OP THE OVARIES. 323 

bolic acid and applied to the entire surface of the endome- 
trium. This treatment must be followed by intra-uterine 
applications of the tincture of iodine and creosote, and the 
usual treatment for metritis as has already been described. 

Electricity may be of benefit in some cases, and can be 
tried. 

Bromide of sodium must be given for the nervous symp- 
toms; and other sedatives, as anise-seed water, spirits of 
lavender, etc., may relieve the reflex symptoms, especially the 
tendency to flatus. 

Oftentimes small doses of bichloride of mercury followed 
by the iodide of potassium or sodium will cause improve- 
ment. This alternative treatment is generally more appli- 
cable to stout than poorly nourished women. The latter do 
better on the iodide of iron given with such tonics as nux 
vomica and quinine. 

In cases where the woman is suffering to such extent that 
her life is useless an operation for removal of the diseased 
organ is justifiable. In case only one ovary is involved the 
other may be left, but it frequently gives trouble afterward, 
a second laparotomy being called for to remove it. If there 
is the least evidence of disease on inspection, both should be 
removed while the abdomen is open. 

Tumors of the Ovaries. — The ovaries may contain neo- 
plasms, which may be either benign or malignant. The 
benign tumors are cystic, fibro-cystic, or fibrous. The malig- 
nant growths are either sarcomatous or carcinomatous. 

Ovarian Cysts may be ^nultiple or single, but the single 
form is usually a compound cyst composed of a number 
of small cysts in one envelope. The multiple cysts are also 



324 MODERN GYNECOLOGY. 

each compound, but each group is in a different part of the 
ovary. 

These cysts may contain papillae extending inward from 
the cyst-wall, or they may contain hair, bone, teeth, fat, etc. 
They are the most common form of ovarian tumor. 

Fibroma of the ovary is rare, aud fibro-cystoma is even 
more rare. They all increase gradually in size and do not 
grow by involving adjacent organs. 

Any of these benign tumors may form adhesions attaching 
the ovary to the various neighboring parts. If the attach- 
ment is to the intestines obstruction may result and fatal 
results follow. 

A pedicel may exist between the ovary and tumor, and 
after the adhesion has formed to some other part this pedicel 
may atrophy from dragging upon it or from twisting and 
the tumor may thus lose its attachment to the ovary and be- 
come attached to some other organ. This process is called 
transplanting. The cysts may rupture, in which case the 
event is sudden, and the contents escape into the general 
peritoneal cavity. Perforation may result from a gradual 
process, and is usually preceded by the formation of adhe- 
sions, consequently no sudden escape of the cyst contents 
occurs. When the perforation is in the direction of a hol- 
low viscus, like the intestine, the contents of the cyst may be 
evacuated in that way. 

Inflammation may be set up around the cyst and may 
go on to suppuration and rupture. If it rapture it may be 
either into the general peritoneal cavity or through adjacent 
tissues into the vagina, bladder, or externally through the 
skin. 



DISEASES OF THE OVARIES. 325 

The Symptoms of ovarian tumor are frequently obscure. 
In fact, none may be present at all ; but there is usually pain 
localized in the ovarian region, with general pelvic discom- 
fort, tenesmus, dragging, and tenderness. The character of 
the pain is neuralgic or " ovarian," and may be more at the 
menstrual period or just before or after that time. 

The menses may be normal if only one ovary is involved, 
the well one causing a normal flow ; but usually there is sup- 
pression of this function. 

The tumor as it increases in size may displace the other 
pelvic organs. The uterus may be pushed aside or the blad- 
der or rectum be encroached upon. When it has attained 
sufficient size the enlarged ovary rises out of the pelvis, pro- 
ducing enlargement of the side of the abdomen. It may 
then press upon the abdominal viscera and produce symp- 
toms resulting from the pressure. Deranged digestion, con- 
stipation, and loss of appetite result. Loss of flesh is apt 
to be a consequence, and chills followed by fever may exist. 
Dragging pains and dyspncena are frequent with these large 
tumors. Death may ensue from the wasting and pressure 
of a very large ovarian tumor. 

Examination of the pelvis will find a tumor to the side of 
the uterus, or if the ovary is prolapsed it may be found in 
Douglas' pouch directly behind the uterus. This tumor is 
usually soft and yielding, smooth and globular. If multi- 
ple cysts are present irregular projections may be felt on its 
surface. 

The examining finger mil find difficulty in distinguishing 
this condition from pyo-, hydro-, or hsemato-salpinx, fibroma 
in the pelvis, pelvic hematocele, or pelvic abscess. The sub- 



326 MODERN GYNECOLOGY. 

sequent history will aid in the differential diagnosis. Feeal 
masses have been mistaken for ovarian tumors, but not in 
the hands of careful men. 

The Treatment is removal by abdominal section, and where 
this is impossible because of excessive adhesions, the result 
is necessarily fatal. 

Malignant Ovarian Tumor is not to be distinguished in 
its earlier stages from the benign form, except where the 
ovary is prolapsed so as to make it accessible to the examin- 
ing finger. The organ is rough to the touch and nodular j it 
is also hard, and the enlargement is more rapid than in the 
benign form. 

The Treatment is removal, if discovered before adjacent 
organs are involved to such extent as to make a radical re- 
moval impossible. 



CHAPTER XIV. 



FIBROMA. 

Uterine Fibroma. — The name fibroma is applied to all 
fibrous growths in the pelvis and elsewhere. Pelvic fibroma 
may be in the mucous membrane of the vagina, within the 
cervix, or inside of the uterus itself . These mucous or sub- 
mucous growths are fre- 
quently spoken of as polyps. 
They may have an attach- 
ment at or near the fundus 
and hang down into the ute- 
rus, and may extend through 
the cervix into the vagina, 
in which case they may 
be difficult to diagnosticate 
from inversion of the uterus. 
The uterus shown in Figure 

93 has polypoid fibroma at- 
tached at the fundus by a 
narrow pedicel. In Figure 

94 the tumor is larger and 
the pedicel broader. Fibro- 
ma in the wall of the uterus or its cervix are called intra- 
mural. They may so uniformly involve the uterine walls as 

to caiise a uniform enlargement of that organ with no evi- 

327 




Fig. 93. Mucous Fibroid. (Martin.) 



328 



MODERN GYNECOLOGY. 



dence of a tumor at any point, or they may occur in one or 
more places, making nodular thickenings. Cancer of the 
uterine body is also apt to take this nodular form and con- 
fuse the diagnosis. Fi- 
brous growths also oc- 
cur on the outer part 
of the uterine body or 
adherent to the tubes, 
ovaries, the parovari- 
um, or in the broad 
ligaments. 

The Symptoms of 
fibroma may present 
a clear-cut picture, or 
they may be so obscure 
as to mislead the most 
careful diagnostician. 
There is usually some 
derangement with the 
menstrual functions 5 
this may rarely take 
the form, at least for 
a time, of amenorrhcea, but the usual history is of an ex- 
cess of the flow to a greater or less extent. Cases of well- 
marked uterine fibroid will also be met with giving positively 
no history of any abnormality in the menstrual flow. The 
first symptom noticed is usually an increased flow. Instead 
of three or four days, the flow will remain five, six, or even 
ten days. The intervals between the menses may change 
and a metrorrhagia be added to the menorrhagia. Menstrua 




Fig. 94. Mucous Fibroid with Broad Base. 
(Martin.) 



FIBROMA. 329 

ation will occur eveiy three weeks, every two weeks, or the 
flow may come one day and miss a day or two only to recur 
in a short time. Daily hemorrhage is more significant of 
disease of the cervix or of cancer than of fibroma. 

Between the hemorrhages there may be pain, lencorrhoea, 
dyspareunia, dysnria, and backache, and there is frequently 
dysmenorrhea and passage of clots with the flow. Symp- 
toms due to pressure on the rectum, as piles, and constipa- 
tion may exist. 

Examination of the pelvis reveals a tumor, which may be 
in the cervix, where its presence is evident, or it may be 
within the uterus, when only the increased size of that organ 
can be felt, or if large enough and adherent by a pedicle 
within the cavity, it may come down through the cervix and 
be felt within the internal os. It may be intra-mural, when 
the examining finger can detect, in addition to the enlarged 
uterus, a hardening of the uterine wall. The tumor may be 
nodular or flat. If a single rounded enlargement exist, it 
may be mistaken for a misplaced fundus in retroflexion, 
anteflexion, or lateroflexion. The sound will clear up the 
true direction of the uterine canal and reveal the presence 
of the tumor in these obscure cases. A very small uterine 
fibroid is usually sufficient to cause much hypertrophy of the 
uterine wall. This is caused by the increased vascularity in 
that organ due to the fibroma. The main difficulty in diag- 
nosis is to eliminate other causes of uterine enlargement. 
Pregnancy is occasionally accompanied by menstruation for 
some months, but a pregnant uterus is soft to the examin- 
ing finger, while a uterus containing a fibroid is hard. The 
characteristic softness of the pregnant uterus around the in- 



330 MODERN GYNECOLOGY. 

ner os 7 as described by Sormtag (Hegar's sign), will prevent 
any error in these cases if the examiner is on his guard. Can- 
cer of the uterus is more rapid in its growth than fibroid, 
though the scirrhus form may be equally hard, and the 
character of the hemorrhage is different. The diagnosis 
may be in doubt until ulceration begins, when the charac- 
teristic odor of cancer will make its diagnosis clear. The 
removal of tissue from the intra-uterine cavity and its mi- 
croscopic examination should be done where doubt exists. 
Hemorrhagic endometritis might confuse, but the uterus, 
though enlarged, is not hard, as in fibroma, and the body of 
the uterus is of uniform consistency. Abortion with retained 
placenta, etc., can be distinguished by the history, by the 
material rejected, and the odor of the discharge, and by what 
the curette brings away. Inflammation of the tubes may 
cause a mistake in diagnosis when so closely adherent to the 
uterus as to seem part of it either at its sides or in Doug- 
las' pouch, for here there may also be repeated hemorrhages. 
But these tumors seldom increase in size, and may get smaller 
at times, while a fibroma usually grows uniformly larger. 
Fluctuation can frequently be detected in the tube and not 
in the fibroid. It is well to remember here that a fibroid 
may seem smaller when the general congestion of the pelvis 
has been lessened by a copious menstruation, but this fact 
should not mislead the physician. A fibroma within the 
uterus will often be found by the sound. It is well also to 
remember that all fibroids of the uterus increase the length 
of the uterine canal. The tumor may stop the sound before 
the fundus is reached and prevent its passage further. 
The Nonsurgical Treatment of fibrous tumors of the uterus 



FIBROMA. 331 

is chiefly palliative. The general treatment aims at getting 
the patient in the best possible, condition of general health 
and environment, and keeping her there. The local treat- 
ment has much the same point in view. Copious hot vaginal 
douches should be used twice daily, and applications of Mon- 
seFs solution should be made to the entire vaginal vault once 
a week, and followed by very tight tamponnading, if the 
latter is well borne. The tampons should be packed in all 
parts of the vagina and should be thoroughly saturated 
with glycerine. Applications to the endometrium are also 
required and should be thoroughly made. The best method 
is by introducing an applicator well wrapped with cotton and 
saturated with the medicine used. The best remedies for 
intra-uterine applications are tincture of iodine, tincture of 
iodine and creosote, equal parts of each, or carbolic acid and 
glycerine, equal parts. In using any of the above prepara- 
tions care must be taken to see that the cervical canal is 
patulous, or serious results may follow from the absorption 
of the sloughs caused and resulting sepsis. The internal use 
of ergot, hydrastis, etc., has been highly extolled by some. 
Dr. J. W. Houston of Oxford, Pa., uses the following and 
claims good results : 

Ext. ergot, fl. 

Ext. hydrast. fl. 

Ext. hamamel. fl aa f j 

M. Sig. 3 j three times daily in water. 

I certainly have seen -cases benefited by the above. It is 
necessary to continue its use for a number of months to see 
its best effects. Medicinal treatment of uterine fibroid only 



332 MODERN GYNECOLOGY. 

does good indirectly, according to Pozzi, ergot by contracting 
the uterus and preventing hemorrhages, and arsenic and 
phosphorus by relieving the mal-nutrition. The hydrastis is 
also very efficient in controlling hemorrhage from the uterus. 
The following is the plan of Hildebrandt : 

Ergotine gr. lxxv 

Chloral hydrat gr. xv 

Aqua, destill ad § iij 

M. 

Twelve minims of the above are daily injected deep in the 
buttock or deltoid muscle, and its use must be persisted in 
for months. Authorities differ as to the effects of ergot on 
these tumors. 

Abdominal Fibroids. — Fibroma may exist in the abdomi- 
nal cavity entirely distinct from the uterus. These growths 
do not enlarge the uterine cavity and there is no metror- 
rhagia. They may be mistaken for ovarian cysts, or vice 
versa. Fluctuation, if found, proves the tumor of cystic 
origin. The cyst develops much more rapidly than the 
fibroma. The gravid uterus has been mistaken for a fibroid 
in the abdominal cavity, and the mistake not discovered 
until the abdomen was opened for its removal. In these 
cases Hegar's sign of pregnancy was present in so marked a 
degree as to cause the examining finger to be unable to 
detect any connection between the cervical portion of the 
uterus and the fundus, the former being mistaken for the 
whole organ and the latter for a tumor. Fibroma of the 
broad ligaments can be distinguished from parovarian cysts 
by the fluctuation in the latter. They may be difficult to 



FIBROMA. 333 

distinguish from pyo- and hematosalpinx, but the history 
and general symptoms usually remove all doubt. 

The Course of fibromata is usually quiet but progressive, 
though it is occasionally rapid and fatal. The menopause 
usually terminates it by atrophy and diminution in size. The 
induction of a premature menopause by castration is because 
of this fact. When the climacteric is near, unless the symp- 
toms threaten life none but palliative measures should be 
used, leaving the cure to that condition. Cases of spontane- 
ous expulsion of auterine fibroid have been observed, when 
the tumor was submucous or intra-mural. The chief danger 
from fibroma is from pressure on the bladder or the ure- 
ters, causing nephritis, on the rectum, and from hemorrhage. 
Pregnancy may cause absorption, but this is not without 
danger. I saw one case in which the sloughing fibroid in 
the uterine wall caused septic absorption after delivery, and 
death from septicaemia on the fifth day. 

Treatment of Pelvic Fibromata by Electricity is based on the 
principles first formulated by Apostoli. It is consequently 
called Apostolus method. He made the abdominal pad large, 
so as to avoid the pain received from strong currents applied 
to a limited surface of skin. These pads are usually made 
of clay inclosed in layers of cheese-cloth. 

The other pole is connected with a metal electrode, which 
is made to lie in contact with the uterine mucous membrane. 
The action of the different poles on the mucous membrane is 
different, the positive pole being that of a caustic acid, while 
the negative pole is that of a caustic alkali. Further than 
this, the positive pole possesses a marked hemostatic effect, 
while the negative pole can be used to destroy small granula- 



334 MODERN GYNECOLOGY. 

tions, vegetations, etc. When hemorrhagic conditions are to 
be treated the hemostatic action of the positive pole is util- 
ized, while the negative electrode is nsed in cases of slough- 
ing from granular surfaces or where redundant tissues are 
to be destroyed. 

The electrode for intra-nterine applications is made of 
platinum and shaped like an ordinary uterine sonnd. This 
is covered with celluloid tubing except at the tip, and can be 
attached to a cord connecting it with either pole of the bat- 
tery. Modern batteries are nsnally made with an attachment 
by which the poles can be reversed simply by turning a small 
lever. This enables the operator to reverse the current with- 
out changing the position of the electrodes. 

As the metritis with fibroma is usually hemorrhagic the 
positive pole is most frequently used, but at times, when it is 
desired to reduce the tumor, the negative pole is used during 
a part of the treatment and followed by the positive pole, or 
one treatment is devoted entirely to the reducing efforts of 
the negative pole, to be followed by the hemostatic effects of 
the positive pole at the next treatment. 

Apostoli insisted that the amount of electricity given 
should always be carefully measured by an amperemeter, 
and that it should be given in definitely known quantities. 

Fibroma treated by the electric current are frequently re- 
lieved. It can hardly be called a cure that leaves the tumor 
in the pelvis, yet in the most favorable cases not only is active 
growth checked and all the symptoms caused to disappear, 
but a marked reduction in the size of the tumor is produced. 
This favorable condition may continue until the onset of the 
menopause makes it permanent, but again the active condi- 



FIBROMA. 335 

tion may start up at any time. This recurrence is equally 
true of any other form of treatment except complete removal 
and possibly the production of a premature climacteric by 
castration. These cases of renewed activity are usually much 
more difficult to control by any but radical measures than 
the first condition was. 

Some of the most prominent surgeons also contend that 
when operation for removal becomes necessary the prognosis 
is not so favorable in cases where electricity has been used. 
Dr. Joseph Price of Philadelphia gives expression to the 
most pronounced opinions against the use of electricity for 
fibroma of any man in America. 

When the fibrous tumor is in the pelvis but not in the 
uterus or adherent to it, the effort is made to cause the elec- 
tric current to pass through it. This is done by placing the 
metal electrode as near to the tumor as possible. At times 
it can be approached better from the vagina, and again the 
interior of the uterus is the nearest point. 

Some critics of this method maintain that no current that 
is not dangerously strong can penetrate the tissues deep 
enough to have any effect on these deep-seated fibroma. 
Others endeavor to overcome this objection by having the 
electrode made sharp at the point and thrusting it directly 
into the tumor. In fibroma within the peritoneum this 
method is attended with danger and is rarely justifiable. 
Cutter, who advocates this method, had four deaths in fifty 
cases, a rather alarming record, and one not calculated to 
encourage its use. 

Figure 95 is taken from Martin's case of multiple uterine 
fibroma This patient suffered from hemorrhage to such a 



336 



MODERN GYNECOLOGY. 



degree as to produce a condition of " aneemia and extreme 
weakness." She had several treatments by cnrettement and 
had a thorough course of ergot without relief, and was then 

treated by electricity for 
four months without the 
slightest effect upon the 
flooding, and finally hys- 
terectomy was done, re- 
vealing the cause of the 
failure of the other treat- 
ment. The many submu- 
cous tumors so distorted 
the uterine canal as to 
make it impossible either 
to curette or cauterize its 
entire interior. The intra- 
mural tumors aided in 
distorting its shape. 
According to some authorities, electricity in the treatment 
of fibroma rarely produces a diminution in size, and the 
apparent reduction is due to the removal or lessening of 
perimetric exudations as a result of rest and the good care 
which always is an accompaniment of its use. Whatever 
effect is produced in reducing the size of the tumor and 
stopping its growth ceases when the administrations cease. 
The good effects from electricity are to lessen hemorrhage 
and pain and improve the general condition. It may be 
tried especially in those cases where operations cannot prom- 
ise a radical cure. Where excessive hemorrhage is present 
the positive pole must be used in the vagina and to the endo- 




Fig. 95. 



Multiple Intra -mural Fibromata. 

(Martin.) 



FIBROMA. - 337 

ttietrium. Where this fails a thorough curetting will often 
control the bleeding. Apostoli claims that the electrode acts 
as an " electric curettage/' and thus removes the cause of the 
hemorrhages., With this idea in view the actual removal by 
an instrument under perfect control will be preferred by all 
surgeons, the work done by a curette properly and thoroughly 
used being certainly more scientific than the indefinite results 
of the caustic action of the electrode in the uterine cavity 
with the uncertain action of the current and the certainty of 
not reaching the whole of the intra-uterine mucous mem- 
brane. A thorough curettement is usually sufficient to relieve 
the hemorrhagic tendency, and often cures it after the elec- 
tricity fails. The detritus loosened by the curette is removed j 
that caused by the current must slough away unless removed 
by the curette afterward, but if the curette is to be used at 
all it seems superfluous to use the electricity. 

The electro-chemical or " interpolar n action directly on the 
tumor is not proved, and its effects are often slight, if any. 
The chief benefit from electricity is due to the contraction in 
the uterine walls it causes, and this can usually be brought 
about better by a thorough curettement. 

Small fibroids in the uterine walls or in the cervix can 
often be enucleated and removed. A sharp curette (Fig. 96) 




Fig. 96. Sims' Sharp Curette. 

will aid materially in removing them, or they may be removed 
by a long-handled forceps ; the latter can best be used when 
the tumor is submucous or polypoid, especially when it oc- 



338 MODERN GYNECOLOGY. 

curs at the cervix. Frequently intra-mural fibroids can be 
removed with a blunt curette. 

Dr. Paul Outerbridge of New York has tied the uterine 
arteries for fibroid of the uterus where enucleation is not 
possible. This is a simple operation as done by him. The 
patient is given an anaesthetic and placed in the dorsal posi- 
tion with the thighs well flexed. The vagina is held well 
open with retractors on either side, giving a clear and easily 
accessible field for operation. The cervix is steadied by 
Skene's tenaculum, and the uterus drawn down if it is mov- 
able. The finger easily detects the pulsation of the uterine 
artery at the side of the cervix. A small incision with scis- 
sors is made over this point down as near to the artery as 
possible without wounding it. A curved needle is then 
passed around the artery, including the tissues, and threaded 
with a strong silk cord and withdrawn, leaving the double 
cord in its track, thus leaving a second ligature in case one 
should slip or break in tying. The cord is then tied and 
drawn with sufficient tightness to stop completely all pulsa- 
tion in the artery. The artery on the opposite side is tied 
in like manner and the patient put to bed. The ligatures 
are to be left in, and after a week's rest the usual intra-uter- 
ine and vaginal treatment is resumed. The uterus gets the 
larger part of its blood-supply by the uterine arteries, and 
tying them off lessens the tendency to hemorrhage, and, its 
inventor claims, causes atrophy of the fibroma. It certainly 
is a much simpler operation than castration and less danger- 
ous, and causes no mutilation, leaving the woman function- 
ally intact. The cases in which I have tried this operation 
were benefited by it. 



FIBROMA. 339 

The radical operation for removal of the fibroid is only 
indicated when other means have failed, and not then unless 
the patient's life is endangered either by incontrollable hem- 
orrhages or by pressure from the size of the tnmor. 

When radical removal is impossible by reason of adhe- 
sions or for any cause, removal of the nterine appendages, 
thus inducing a premature menopause, may cause an arrest 
of the fibrous growth. In careful hands this operation is 
not a particularly dangerous one, jet it should not be hastily 
urged, and cases are met with in which it fails to give relief. 



CHAPTER XV. 

CARCINOMA. 

Carcinoma. — A special chapter devoted to carcinoma may 
seem unnecessary in a treatise on gynecology, and especially 
so in a book devoted to therapeutic gynecology, yet it is re- 
quired to make this work complete. 

Location.— The pelvic organs may all become the seat of 
cancerous disease. The most common situation, probably 
from its liability to injury, is the cervix uteri. Cancer may 
also occur in the body of the uterus, in the vagina, in the 
vulva, in the ovaries or the parovarian tissue, and in the 
tubes or broad ligaments. 

The Course of cancer in the pelvis is progressive, and re- 
quires little consideration except that called for by the modi- 
fications in its progress due to its environment. Its constant 
tendency here as elsewhere is to invade adjacent tissues and 
eventually to break down in sloughs, causing destruction of 
the parts invaded, until death puts an end to its fatal prog- 
ress. This may occur in several ways. Hemorrhage may 
result from destruction of a blood-vessel before it has been 
occluded by infiltration of the diseased tissue or by clot. The 
amount of bleeding depends on the size of the artery or vein 
broken into. It may be fatal in a veiy few hours, or several 

hemorrhages may occur each depleting the patient and mak- 

340 



CARCINOMA. 341 

ing her weaker, until she dies of simple inanition ; or a small 
hemorrhage or two may occnr early and be entirely recov- 
ered from, leaving the patient to be destroyed in some other 
way. Absorption of septic material from the slonghing sur- 
face may cause general septicgemia and death. 

The case may linger on for many months, growing grad- 
ually weaker and weaker from the effects of the disease 
and its discharges, and from the almost constant pain, until 
she is left entirely devoid of strength and almost devoid of 
anything but skin, bone, and sloughing sores, dying at last 
worn out with the hopeless struggle, death being welcomed 
as a long-delayed relief. 

Complications resulting from the cancerous disease may 
prove fatal, the most common being nephritis ; or metastatic 
growths of a malignant character may form in other organs, 
causing a fatal termination. 

Symptoms. — The important thing for consideration in can- 
cer is an early diagnosis. The most distinctive symptom of 
cancerous growth is pain. This is usually present early in 
the disease, and is of a sharp, piercing character. 

Cancerous growths in the vulva and vagina are easily 
accessible, and an early diagnosis is thus rendered easy. 
This is equally true when the disease is in the cervix or even 
in the body of the uterus. At any of these points a portion 
can be removed and the diagnosis established by microscopic 
examination. The importance of using this means of remov- 
ing all doubts as to the true nature of the disease cannot be 
overestimated. The only hope of radical cure depends upon 
the diagnosis being established at the earliest possible mo- 
ment, The microscope is a certain test m proving the pres- 



342 MODERN GYNECOLOGY. 

ence of carcinoma. Failure to find the germs can only estab- 
lish its absence after examination of a number of specimens 
taken from various parts of the suspected tissues. 

When the disease is in the parametrium or in or around 
the appendages its presence can only be suspected at the 
first examination. The differences between fibroma and 
malignant tumors of these parts are not always clearly de- 
fined. As has been said, there is usually more pain with 
cancer than with fibrous growth, and the latter is less likely 
to be nodular. The hemorrhage from cancerous disease is 
different from that with fibroma, there being more tendency 
to a regular daily discharge of bloody leucorrhoea. This 
difference is not so marked until sloughing has begun on 
the cancerous surface. The metritis complicating the early 
stages of one is not to be distinguished from that with the 
other. The progress of cancer is more rapid than fibroma 
and the involvement of adjacent tissues more extensive. 
The fibrous tumor grows in size, but not by involving other 
organs as does cancer. In the later stages of cancer the 
peculiar odor of the discharges is not to be mistaken. The 
diagnosis can be made by it alone before the patient has 
been seen. The peculiar hue of the skin of patients in whom 
cancer has ceased to be a local disease is also characteristic. 

Cancer of the External Genitalia, if seen early, can be 
radically removed. The accompanying picture (Fig. 97) is 
taken from a photograph of an unpublished case of Dr. John 
Woodman of New York. The condition is shown before the 
removal of the entire left labia majora and its corresponding 
nympha. Three enlarged glands were also removed from 
the inguinal region. I assisted at the operation, and the 



CARCINOMA. 



343 



carcinomatous character of the growth was established by 
microscopic examination. There was no recurrence of the 




Fig. 97. Cancer of the Vulva, taken from Dr. Woodman's Case. 

growth at the expiration of two years, when she was lost 
sight of. 

Cancer of the Cervix has some peculiar characteristics 
that will at least lead to a more thorough investigation. The 
cervix is usually the seat of laceration which has been neg- 
lected for a number of years. There is hypertrophy, which 
is frequently at the lowest point, giving a " cauliflower" shape 
to the cervix. The consistency is not so dense as that of 
simple hypertrophy, and the hard resistance given by fibrous 



344 MODERN GYNECOLOGY. 

growth is absent. Instead of these there is a spongy im- 
pression given to the examining finger, as if the parts were 
saturated with fluid and ready to break down at any time. 
At the highest limit of this softer tissue a zone of quite hard 
tissue is frequently felt. The cancerous growth in the cervix 
may be limited to a small spot or it may involve its whole 
circumference. When the body of the uterus is invaded by 
the disease it is hard and unyielding to the finger at the 
side, and nodules or irregularities are frequent. These must 
not be mistaken for multiple fibroids of the uterine wall, 
which are smoother over each individual . tumor, while the 
malignant tumors are irregular in form and broken by de- 
pressions and elevations. When the entire uterus is involved 
in a cancerous growth it may be smooth and uniform in size. 

The Treatment of carcinoma depends upon the stage when 
it comes under observation. The importance of an early 
diagnosis is great. When there is no systemic involvement 
indicated by cachexia, and the local involvement is such as 
to permit it, a radical removal with the knife will perma- 
nently cure the disease. This removal must include every 
particle of tissue that has been invaded by the disease. 
Veins that have become occluded by coagula must be fol- 
lowed and dissected out, as well as all lymphatic vessels and 
glands that are in any way involved. Recurrence is only 
evidence that some diseased point has escaped the knife. 

Some physicians who do not use the knife to a sufficient 
degree to feel perfectly at ease with it express a preference 
for the electro-cautery for the removal of cancer. This is 
not a satisfactory method, as it does not give the necessary 
opportunity to examine the margin and be assured that all 



CARCINOMA. 345 

the diseased tissue has been removed or destroyed, and it 
cannot be so perfectly controlled. 

Caustic pastes have been nsed for the destrnction of ma- 
lignant growths, but these have usually been the resort of 
quacks, and are unscientific and in no sense reliable. They 
are usually made from the chloride of zinc or some similar 
caustic. 

When the diagnosis of carcinoma of the cervix has been 
established and the disease is limited to that portion of the 
uterus, its removal is the only justifiable treatment. This 
can be done even when the diseased area extends almost to 
the fundus. A high amputation of the cervix can usually 
remove all the involved tissue. When the fundus has been 
invaded by the malignant growth the question of operation 
is yet sub judice. Some surgeons advise removal of the 
whole organ, either by vaginal or abdominal hysterectomy, 
while others oppose any operation ia these cases. When the 
vagina has been extensively involved in the diseased process, 
and especially when the walls of the bladder or rectum have 
been invaded, few surgeons will advise operation. My ex- 
perience with amputations of the cervix is not favorable, 
while hysterectomy by the combined method is usually suc- 
cessful, and recurrence is rare. 

Palliative Treatment. — When the general systemic symp- 
toms show plainly that the disease has become general, 
operation can only be palliative. Such palliative operations 
are justifiable. If a sufferer with incurable disease can be 
given a few months of comparative comfort and her life pro- 
longed for a short space of time, she should be given the 
opportunity to have an operation done, A clear statement 



3-16 MODERN GYNECOLOGY. 

of her condition and the object to be attained by the opera- 
tion should be laid before her and her family before it is 
done, and the decision should rest largely with them. 

Removal of flat surfaces with the sharp curette is often 
classed among the palliative measures for cancer. Yet cases 
are seen in which the whole of the involved tissue can be 
removed in this way. The curette is frequently used in 
vaginal cancer, where excision with knife or scissors would 
be liable to invade the adjacent rectum or the bladder or 
urethra. The entire vaginal wall can be removed with a 
sharp curette, and the progress of the disease at least re- 
tarded materially if it is not entirely cured. Cancer of the 
endometrium, either cervical or corporeal, when limited to 
the mucous layer can be removed in the same way. The 
sharp spoon or curette will often check for a time the prog- 
ress of the cancer located at the cervix when there is much 
ulceration and yet too much infection of surrounding tissue 
for removal by hysterectomy. 

The Use of Drugs for the treatment of cancer properly oc- 
cupies a secondary place in the consideration of this disease. 
Yet they have a legitimate place, and their consideration is 
of special importance to the gynecologist. The remedies 
employed have many enthusiastic advocates, some of whom 
advise their use to the exclusion of other measures, even in 
cases where the nature of the disease is clearly demonstrated 
early enough for complete removal by the knife. They 
claim to cure by local applications and internal remedies. 
Where the disease is limited and the diagnosis even reason- 
ably certain, it seems like wasting valuable time to trust to 
medicinal efforts at cure. Few surgeons will be willing to 



CARCINOMA. 347 

take this risk. Consequently the virtues of these remedies 
are extolled almost exelusively by physicians who do not 
operate. 

Their use does produce good results at times, and while I 
know of no records of cured cases in which the diagnosis was 
established beyond doubt by the microscope, yet many " sus- 
picious " cases have recovered under this plan of treatment. 

These applications form the only treatment left in cases 
where operation is contra-indicated from any cause. In this 
class of cases are those who cannot take an anaesthetic be- 
cause of heart disease or advanced kidney involvement, also 
those who decline operation, and cases where the stage of the 
disease or the parts involved make operation unwise. Local 
applications are also used to prevent recurrence after opera- 
tion, and where the operation has been only palliative to 
delay the progress of the disease as much as possible. They 
are also useful to promote healing of surfaces that have been 
denuded by the curette and to limit the progress of destruc- 
tion where sloughing is present. 

Tincture of iodine has long been used as an application 
for cancer. Strong solutions of nitrate of silver have also 
been tried. A solution containing equal parts of beechwood 
creosote and tincture of iodine is a more recent remedy. 
Cases of cervical slough which had been declared to be 
cancerous by several gynecologists from the microscopic 
appearance have been healed by continuous treatment with 
this solution. Several such histories have been under my 
notice and verified ; but in none of them has the diagnosis 
been verified by the microscope. None of these cases have 
yet been published, 



348 MODERN GYNECOLOGY. 

The tincture of iodine and creosote is applied on a cotton 
applicator every third or fourth day, and no tampon is used 
after it. The parts should be well saturated with the solu- 
tion and the most scrupulous cleanliness maintained between 
the treatments. This remedy certainly acts in a decided 
manner in checking the progress of cancer with ulcerating 
surface in the genital canal. The sloughs become less offen- 
sive and the sloughing is decreased in a remarkable degree. 
The pain and general systemic symptoms are diminished, 
and the opportunities for septic infection are reduced to a 
minimum. There can be no doubt that the period of life 
and usefulness is materially lengthened by the use of this 
remedy. 

When the slough is in the vagina it is well to take a small 
piece of absorbent cotton in the dressing forceps and satu- 
rate it thoroughly with the solution. This is then placed in 
contact with the surface of the sore, and gentle pressure 
causes it to cover the diseased surface. If the slough is 
within the uterus, the cervix should be dilated so the appli- 
cator can enter the cavity and a considerable quantity of the 
solution be left there. It is well for the patient to be treated 
at her home, and to remain in the recumbent position for 
some minutes after the application is made. If the slough is 
external she may make the application herself about every 
second day, if it is not convenient to have the physician call 
so often. 

Methyl blue has been used more recently, and it is claimed 
that it will heal the ulceration of malignant growths even 
more rapidly than the creosote. It is applied in the same 
manner, Pepsin in powder or solution will cleanse a cancer- 



CARCIttOMA. 349 

ous ulcer by digesting the necrotic tissue and thus, destroy- 
ing the offensive odor so characteristic of these sores. It 
should be daily used to promote the comfort of the patient 
and her attendants. It is doubtful if it has any effect upon 
the cancer itself except that of producing cleanliness. 

This cleanliness is a most important element in the treat- 
ment of cancer of the genito-urinary apparatus. Copious 
warm- water douches must be taken, and frequent bathing of 
exposed parts is necessary. A twenty-per-cent solution of 
carbolic acid is very efficient as a cleansing douche. It 
should be used daily. 

Salol in powder or solution may be used to keep the sur- 
faces clean, and with carbolic acid may be added to the hot- 
water douches to destroy the odor, or pepsin can be used in 
the same manner for this purpose. 

The Internal Treatment for cancer is largely symptomatic. 
The so-called specifics mentioned from time to time have all 
failed to stand the test of scientific investigation. Arsenic 
has probably been used in this way longer than any other 
remedy, yet no case of cure from its use in which the diag- 
nosis was made beyond a possibility of a doubt is on record. 
Arsenic is an excellent tonic and agrees remarkably well 
with some people. Cases of seeming improvement from its 
use are probably due to this fact. 

The cancerous bacillus has been sought for for a number 
of years. Several investigators claim to have discovered 
it, but a reasonable doubt of its discovery still exists in 
the minds of medical men, many of whom even doubt its 
existence. 

The treatment of cancer by electricity has been described 



350 MODERN GYNECOLOGY. 

by Dr. J. Ingles Parsons. His method is to pierce the tumor 
and the tissues for some inches around it with fine needles, 
so as not to injure the skin or mucous membrane. A strong 
galvanic battery is used, and the strength of the current is 
carefully measured. As much as six hundred milliamperes 
are used in some cases. The applications are made under an 
anaesthetic, the pulse and respiration being carefully watched 
as the strength of the current is increased. 

Dr. Parsons thus summarizes the effects produced by the 
action of electricity. It causes " a cessation of growth, grad- 
ual disappearance of pain, some shrinking and hardening 
of the tumor, and enlarged glands, followed by improved 
nutrition and a better state of the general health. The 
growth as a whole does not disappear but remains as an 
inert mass composed in all probability of fibrous tissues 
alone." 

The advantages claimed for the electricity in treatment of 
cancer are that no destruction of tissues nor loss of blood 
accompanies its use ; that it may be repeated at any time or 
any number of times ; that the patients are not laid up by 
its use for more than a day or two ; and finally, that the 
current can be made to pass through parts of the body inac- 
cessible to treatment with the knife. To give the electricity 
for cancer of the uterus, the affected part is transfixed with 
a number of fine needles attached to the negative pole of the 
battery. The positive pole is attached to a pad of clay or 
absorbent cotton, which is applied over the abdomen. A 
current of from one hundred to two hundred and fifty milli- 
amperes can be borne by some patients without an anaes- 
thetic. 



CARCINOMA. 351 

Some authorities claim good results with currents of from 
twenty to fifty milliamperes. But the best results are claimed 
for the more powerful currents. 

At times needles are indicated at both poles in order to 
bring the electrodes nearer together. The needles at the 
positive pole must be made of platinum, or some other sub- 
stance that will not be attacked by the action of the elec- 
tricity. 

Electricity is one of the palliative remedies for cancer, to 
be used when for any reason radical removal is not feasible, 
but its use is not to be recommended in cases that can be 
cured by the knife. 

Crystals of the chloride of zinc will destroy a hard cancer- 
ous nodule by actual burning. This is especially applicable 
to nodules in scar tissue where the disease shows a tendency 
to recur after operation. No scar results from its use, but 
a healthy slough forms under it. Cocaine can be applied 
before using the crystal, as the burn is quite painful. 



CHAPTER XVI. 

PELVIC HEMATOCELE. 

Pelvic Hematocele. — Dr. T. More Madden defines pelvic 
haematocele as " a circumscribed collection of blood effusion 
wholly or partially situated within the pelvic cavity, either 
in its peritoneal or in its cellular structures. This makes an 
intra-peritoneal form, which is usually the result of an extra- 
uterine pregnancy, and an extra-peritoneal form, which may 
be due to the same cause, but is more frequently due to men- 
strual abnormities." 

Intra=peritoneal Haematocele. — Mr. Lawson Tait says he 
has " never seen an intra-peritoneal haematocele that was not 
due to a ruptured tubal pregnancy." The weight of recent 
opinion is that the tube is the general if not the only seat of 
these extra-uterine pregnancies, causing hemorrhage into the 
peritoneum. Cases arising from ovarian, abdominal, or in- 
terstitial extra-uterine pregnancy are rare, and all but the 
last so rare as to be curiosities. They are enumerated by 
some authors, but no cases cited that have been put to the 
test of operation or post-mortem examinations. The inter- 
stitial form is tubal, but in that part of the tube embraced 
by the uterine tissue. It calls for no special mention at this 
time. 

The rupture of the gestation cyst to form haematocele is 

352 



PELVIC HEMATOCELE. 353 

always during the early stage, before or dining the second 
month, and usually before the condition is diagnosticated. 
Rupture at a later period causes shock, hemorrhage, and 
death, unless very prompt surgical interference is had. 

Rupture of a Graafian vesicle producing hemorrhage from 
the ovary or its peritoneal covering, and hemorrhage from any 
of these parts due to malignant disease, are given as causes 
of intra-peritoneal hematocele. These are very seldom 
met with, and the first is by some considered as improbable 
at least. 

The Symptoms are usually those of rupture of the tube. 
There is more or less shock, depending on the size of the 
pregnancy, accompanied by severe pains low down in the 
abdomen, and usually confined to one inguinal region. There 
is generally a chill, and weak thready pulse, and the usual 
symptoms of hemorrhage ; these symptoms gradually lessen, 
and the patient becomes comfortable but weak. She may 
remain so for a considerable period, but usually when she 
begins to move about there is a return of the bleeding, 
causing a recm'rence of the symptoms. 

Local Examination will reveal tenderness, which may be 
limited to one point, but is more generally diffused over the 
whole abdomen. The abdomen is swelled and usually tym- 
panitic. 

On examination per vaginam a tumor is found which may 
be at either side of the uterus, but is usually behind that 
organ, causing bulging into the posterior cul-de-sac of the 
vaginal vault. This tumor is soft, fluctuating, and diffused, 
so that its outlines cannot be clearly made out. It may have 
a " doughy " feel if partial coagulation of the blood has begun. 



354 MODERN GYNECOLOGY. 

The Treatment of this condition is the outgrowth of modern 
gynecological research. The application of the principles of 
general surgery demands the immediate removal of the cyst 
"by abdominal section, followed by a thorough irrigation of 
the peritoneal cavity. 

Extra=peritoneal Hematocele is more frequently met 
with. This condition is very often due to a tubal pregnancy 
rupturing between the peritoneal folds of the broad liga- 
ment. A tubal pregnancy may so rupture as to cause the 
extravasation of blood to be in the cellular tissue adjoining 
the uterus (Madden). 

Another cause of this form of hsematocele is sudden sup- 
pression of a normal menstruation by an obstruction, or 
from cervical stenosis. The blood may first be dammed up 
in the uterus and escape thence into the tube and surround- 
ing tissue, or it may be from an effusion of blood from the 
vessels, first into the tube and thence into the connective 
tissue. 

The immediate exciting causes of extra-peritoneal haema- 
tocele are sudden suppression of the menses, violent exercise, 
intense mental emotion, over-fatigue, excessive or rude coi- 
tion or coitus during the menstrual flow, injuries to the 
abdomen, exertion too soon after miscarriage, and violent 
straining. 

The Symptoms follow one of the above-mentioned causes, 
the most prominent being hypogastric pain with fever, fol- 
lowing some menstrual derangement, to which may be added 
irritability of the bladder. 

Examination reveals a tumor behind the uterus or in the 
iliac region. At first this is soft and fluctuating, but it 



PELVIC H^IATOCELE. 355 

becomes gradually firmer. The symptoms often develop 
gradually. The tumor may be so large as to appear above 
the brim of the pelvis or in the iliac region, or it may press 
on the vagina or rectum. It may displace the cervix in any 
direction. This tumor has fluctuation at first, and later on 
has a " doughy " feel, and it may be softer in some spots than 
in others. 

Treatment of Extra-peritoneal Hematocele depends on its 
cause. When due to ruptured extra-uterine pregnancy, the 
least done the better, as the tendency is to spontaneous cure. 
If tapped, the cyst will fill again and kill the patient from 
concealed hemorrhage. Where the causes of the haematocele 
are menstrual other treatment may be needed to promote 
its absorption. The iodide of potassium and bichloride of 
mercury with quinine in some form acts well in many cases. 
Local applications to the vaginal vault assist materially. The 
best remedy for this is liquor ferri persulphate (Monsel) in 
full strength copiously applied, and followed by a tight pack- 
ing with boro-glycerine tampons. This treatment should 
be repeated twice each week, the vagina being thoroughly 
douched between the treatments. These douches should be 
hot (110° to 115° F.) if all tendency to bleeding has passed. 

When the haematocele undergoes suppuration and becomes 
a pus cavity it should be evacuated. This can usually be 
safer and more thoroughly done through the abdominal 
cavity than by vaginal puncture. At times the resulting 
abscess is low in the pelvis, and fluctuation can clearly be 
made out, usually either behind the cervix or in front of it. 
In such cases, when convinced that the plastic exudation 
has made a complete barrier between the abscess and the 



356 MODERN GYNECOLOGY. 

peritoneal cavity, its evacuation through the vagina is the 
proper treatment. After the pus has escaped the opening 
should be dilated, the cavity thoroughly cleansed and packed 
firmly with aseptic gauze. This dressing must be changed 
frequently, and no douching allowed. If it is impossible 
to make an opening large enough to pack the abscess with 
gauze, a large drainage tube should be worn and the cavity 
irrigated with boiled water. Care must be taken not to use 
much force in injecting this water, as it may break down the 
barrier and escape into the peritoneal cavity. The drainage 
should also be so complete as to leave no possibility of any 
fluid being allowed to remain in the cavity. Where the 
opening is large enough to make the whole cavity accessible 
it is preferable to cleanse it with swabs of absorbent cotton 
saturated with hot water. These should be used over the 
whole inner surface of the abscess, and then it should be 
dried with more aseptic cotton before reapplying the gauze. 
This treatment of abscesses in the pelvis resulting from 
hsematoeele is equally the treatment for pelvic abscess from 
any other cause. It is the rational surgical treatment of 
abscess wherever found, and should always be promptly 
employed when the diagnosis is made. 



CHAPTER XVII. 

STERILITY. 

The gynecologist is frequently asked to treat women whose 
sole cause for complaint is that they do not get pregnant. 
In many of these cases it is the husband who is dissatisfied, 
and the wife applies for relief because she desires to gratify 
his desire for children. The husband frequently complains 
that the sterility is because the wife " does not love him as 
she ought." 

Much domestic unhappiness is often the result of the ina- 
bility to have children, and the physician who remedies the 
condition will win credit for himself and give happiness to 
his patients. The causes are oftentimes of a trivial nature 
and easy to remedy. It is advisable never to give up a case 
as incurable until a cause of a permanent nature is found. 
Much diligent investigation is at times required to discover 
where the fault is. The most searching inquiry into all the 
details of the conduct of the patient before, during, and after 
the act of copulation is sometimes necessary before it can be 
found. When found, the cause is frequently so small a cir- 
cumstance as to be easily overlooked. 

Causes. — The causes of sterility may be divided into three 
classes : those due to the male, those due to the female, and 
those due to the pair. 

357 



358 MODERN GYNECOLOGY. 

Causes Due to the Male do not call for extensive consid- 
eration here, but they should be eliminated when no cause is 
apparent in the woman before subjecting her to uncalled-for 
treatment. The most frequent causes are syphilis, gleet, im- 
potence from excess, and the consequences of the abuse of 
alcohol. It is advisable in most cases to have an interview 
with the husband, to examine him thoroughly, and to sub- 
ject his semen to a microscopical examination. Some of the 
above-mentioned causes can be overcome, and the man must 
be told of his condition and that the sterility is a result of it. 
Treatment on the proper lines will naturally follow with a 
result depending on its curability. Many women have been 
subjected to treatment and fault-finding because of a steril- 
ity in which they were in no sense a factor. It is the duty 
of such a woman's physician to find the cause and locate the 
fault where it belongs. It may not be advisable in all cases 
to tell the woman the cause of the trouble. 

The husband may have tubercular disease of the testicles 
or any involvement impairing his sexual organs. These 
organs may be congenitally imperfect, or the imperfection 
may have been acquired from injury or disease. The treat- 
ment of causes due to the male is not given here. It is 
necessary, however, for the gynecologist to appreciate their 
importance and cause an investigation for them to be made 
in all cases where the least uncertainty exists. He may save 
his patient much unjust censure by bringing to the knowl- 
edge of the husband the fact that he himself is the cause of 
his being childless, and not the wife. 

The Causes Due to the Female are of special importance 
to the gynecologist. Many of them have been mentioned in 



STERILITY. 359 

the foregoing pages. When due to the absence of the ova- 
ries or atrophy of these organs and consequent loss of func- 
tion the case is incurable. The sterility of stout women who 
have progressively increasing plethora, scanty menstruation, 
and loss of sexual desire is also usually not benefited by 
treatment. When the sterility is due to stenosis of the cer- 
vix with congenital anteflexion the treatment of these con- 
ditions will frequently cure it. When due to long, narrow, 
infantile cervix, amputation of a part of this organ will effect 
a cure. When anteflexion of the uterine neck is present, 
removing the cervix and external os from a position of easy 
contact with the semen, reposition is usually sufficient. Ster- 
ility from metritis is common, and persists until the uterine 
inflammation is cured. When associated with salpingitis 
or pyo-salpinx the outlook is unfavorable, as these conditions 
are seldom cured without destroying the function of these 
organs. Sterility may be a consequence of diabetes or other 
disease of the general system, when its cure depends upon 
the results of treatment of this condition. Occasionally 
sterility is due to a hyper-acidity of the vaginal, discharges. 
I have cured several cases by recommending alkaline douches 
before retiring. Sterility may also be due to excessive coi- 
tus. This is frequently the cause existing in newly married 
couples. 

Treatment. — The treatment of sterility due to the woman 
has already been indicated in a great measure in speaking of 
the causes. When the mucous membrane lining the cervical 
canal is so thickened by congestion as to completely fill its 
caliber, passing a large sound has frequently been followed 
by the entrance of spermatozoa from the next act of coition, 



360 



MODERN GYNECOLOGY. 



and resulting pregnancy. If this does not secure sufficient 
patulency of the canal an Outerbridge drain can be intro- 
duced and worn. This is the purpose for which these drains 
were first used (Fig. 98). If the sterility is due to a faulty 

position of the cervix in an 
anterior direction, the ex- 
ternal os may be bathed 
in semen by having the 
woman turn on her face 
immediately after its dis- 
charge into the vagina. 
The use of alkaline injec- 
tions in cases of extreme 
acidity in the vagina has 
already been mentioned. 
The bicarbonate of sodium 
and borax are probably the 
best remedies to use for 
this purpose. The douches 
should be small and taken 
j ust before retiring. When 
due to excess it is advisable for the wife to leave her home 
for a few weeks unaccompanied by her husband. Concep- 
tion will frequently follow shortly after her return. In 
many cases the sterility is due to seemingly trivial causes, 
and much care is required on the part of the physician or 
they may be overlooked. 

Causes Due to the Pair. — Cases of sterility are frequently 
met in which the condition is not due to any cause existing 
in either the man or woman individually. Either with an- 




Fig 



Outerbridge Drain Worn to Cure 
Sterility. 



STERILITY. 361 

other mate would probably have children, but for some rea- 
son they do not have with each other. The causes of this 
condition are obscure, nothing being positively known ex- 
cept the fact that such cases do exist. Many theories have 
been suggested to account for it. Consanguinity has been 
given as a frequent cause. The chief importance of this con- 
dition is its appreciation. Its treatment has no significance. 



APPENDIX. 

INSTRUMENTS AND OFFICE APPLIANCES. 

The physician who treats women in his office must have a 
few instruments and appliances there. A number of these 
have been mentioned in the preceding pages, and their use 
explained in describing the treatment in which they are 
used. Others have been mentioned, but no description of 
them given. A few pages devoted to the subject of instru- 
ments, appliances, and medicaments will not be amiss, and 
are here given. 

The Office for the treatment of gynecological cases must 
be light and roomy. The light from northern windows is 
better than the direct rays of the sun. The upper sashes 
of the windows had best be used, for a number of reasons. 
It gives the light from a better direction for using in the 
majority of cases, and it makes it possible to cover the lower 
sashes with curtains. These sash curtains protect the room 
from the inquisitive outsider, and they give the patient 
confidence. 

The Screen. — It is advisable to have a screen to surround 
the table. The patient will feel better if she cannot see the 
table while she gives her history and tells her symptoms. It 
is also better when some one is with her that the table be 
behind a screen so arranged that every movement of the 

363 



364 



MODERN GYNECOLOGY. 



physician is not under surveillance. The screen is also con- 
venient for her to retire behind to arrange her clothing 
before and after her treatment. It should be about as high 
as an average woman's head, and there should be three or 
four folds to it, so it can be bent around the table in the 
shape needed. It may be decorated, and thus be an orna- 
ment as -well as a useful article. 

The Table was described on page 20 and its essential feat- 
ures mentioned. The number of tables and chairs in the 
market is so great that a simple enumeration of them all 
would require more space than I have at my disposal. My 

first gynecological table was 
of my own construction, and 
it was used with perfect sat- 
isfaction for about six years. 
It cost less than ten dollars, 
the chief expense being the 
amount paid a blacksmith, 
who made the foot-rests. I 
show in Figure 99 a table 
that I have used, and find it 
fills all the requirements of 
a table. It is not shown because it is thought to be the best 
table in the market, but because it is simple of construction 
and answers every need. I have no doubt that other equally 
good ones are made. As a rule, the cheapest and least com- 
plicated tables are the best. Strength, simplicity, and con- 
venience are the chief essentials. 

The Cabinet. — Much has been said about applications in 
giving the treatment of the diseased conditions to the 




Fig. 99. Daggett's Table. 



APPENDIX. 365 

description of which the preceding pages have been de- 
voted. It is necessary to have some place to keep these 
snbstances at hand for use when indicated. If this recep- 
tacle will also hold the instruments needed for routine 




Fig. 100. Instrument Cabinet. 

treatment in- the office an added convenience is obtained. 
The cabinet (Fig. 100) is intended to serve both these pur- 
poses. The four revolving shelves will hold the instru- 
ments for ordinary use, the movable shelf is at hand for 
larger instruments, and the drawers are large enough for 



366 MODERN GYNECOLOGY. 

cotton, tampons, and supply bottles. The jars for immedi- 
ate use will be most within reach if placed on top of the 
cabinet. This top is more desirable if it is covered with a 
thick plate of glass. The glass top will not stain or be 
injured in any way by the chemicals that may be spilled 
upon it, and it can be kept perfectly aseptic with little care. 
The cabinet is not made with these glass tops, but one can 
be obtained from the dealer, who will also send a man to 
put it on. 

The Jars for drugs should also be glass with glass cov- 
ers. The best are of uniform size from the bottom up, the 
mouth being the full size of the jar. The lid should fit over 
and rest on a depression cut around the outside of the top. 
For ordinary drugs four-ounce jars are large enough. Two 
eight-ounce jars will be convenient for glycerine and the 
boro-glycerine solution. Some drugs will require different 
receptacles because of their chemical properties. The ni- 
trate-of -silver solutions must be kept in amber jars, those 
holding an ounce being large enough. If vaseline is used 
it can be kept in a similar glass jar, but some of the 
refined antiseptic oils are cleaner and pleasanter for both 
patient and physician. If it is deemed advisable to keep 
some vaseline at hand, the white vaseline is put up in tubes 
such as paints are kept in. A number of these tubes can 
be kept on one of the shelves with the smaller instruments. 

The Solutions. — Having secured the jars, it is next in 
order to fill them. No attempt will be made to give all the 
remedies that have been advised, but the solutions I have 
at hand will be given. Each physician will discover his 
favorites and use them, and in many cases do much good 



APPENDIX. 367 

with them. No one should limit his work or armamenta- 
rium to the list of any one man. 

The first large jar contains pure glycerine, the second the 
boro-glycerine solution. This I prepare according to the fol- 
lowing formula : 

Glycerine. 
Borax pulv. 

Alum pulv aa § iij 

M. 

Considerable stirring is needed to make a solution, but it 
can usually be secured. If all the powders do not dissolve, 
a little more glycerine may be added. If the alum is ob- 
jected to it can be omitted, and the glycerine and borax 
mixed in equal parts. But usually the pure glycerine will 
answer where the alum is not required. 

One of the smaller jars will contain the iodine and creo- 
sote mixture. 

Tine, iodine. 

Creosote (beechwood) aa § j 

M. 

Another will contain : 

Acidi carbolici. 

Glycerin aa § j 

M. 

A third will contain about an ounce of the liquor fern 
persulphatis (Monsel). This jar must not be filled too full, 



368 MODERN GYNECOLOGY. 

and will require frequent emptying and replenishing. The 
fluid will evaporate if it is not kept tightly stoppered, and 
an insoluble powder is left which is useless. Much waste is 
avoided by putting only a small quantity in the jar at a 
time. A jar containing pure tincture of iodine is conven- 
ient. This will also evaporate rapidly and leave a concen- 
trated solution, which may cause surprise by the intensity 
with which it burns when applied. Churchill's tincture of 
iodine is much used. The most popular formula is : 

Iodi 3 v 

Potassi iodidi 3 j 

Aqua l j 

Vin. rectif § iij 

M. Sig. Churchill's tincture. 

It is perhaps better to keep these iodine solutions in dark- 
colored glass-stoppered bottles than to put them in the jars 
for use. They all evaporate, and some of them change 
chemically from exposure to light. 

A bottle of pure carbolic acid should also be at hand, but 
must not be left exposed. A solution of tannin in glycer- 
ine is much used. A china jar of powdered tannin is better 
perhaps. 

The solutions of nitrate of silver must be in amber ves- 
sels. The stronger should be : 

Argent, nitrat 3 j 

Aqua, destill § j 

M. 



APPENDIX. 369 

The other silver solution is : 

Argent, nitrat gr. xv 

Aq. destillat . . . . , 3 j 

M. 

A Suitable Lubricant for the examining fingers and for the 
specula and sounds should be at hand on a convenient table. 
Many substances are used. Vaseline is more used than any- 
thing else. It will not become rancid, no matter how long- 
it is kept. Its chief objection is its action on the hands of 
the physician, having a tendency to make them rough and 
to chafe. For dispensary work a solution of castile soap is 
convenient. The dirt and soap can be removed at one wash- 
ing. The chief objection to the soap is the smarting it occa- 
sionally produces in sensitive women. Cold cream or olive 
oil with a little carbolic acid rubbed through it will keep 
well, and is convenient in private practice. Some of the 
volatile oils, like glymol, will remain sweet without any 
antiseptic. I use voschano oil in private practice, both for 
the hands and speculum. It does not chap the hands or 
make them harsh, and causes no irritation to the patient. 

A bottle of tincture of green soap should be in the office. 
It is convenient in many ways, and cleansing. A few drops 
added to a small basin of water is convenient to drop soiled 
instruments in or to bathe the hands. 

The Basins.-^-Two small round agate-covered basins are 
always at hand. They are one third filled with water, the 
one containing about ten drops of the tincture of green 
soap, the other ten drops of carbolic acid. The water in 
each is warm and is changed, and the basin thoroughly 



370 MODERN GYNECOLOGY. 

washed after each treatment. It is more convenient to 
have enough basins to change after each patient. 

A slop- jar to receive waste pieces of cotton should be at 
the physician's right. 

A low stool for the patient to step on in mounting the 
table is useful, and a low chair for the physician completes 
the furniture. Of course plenty of clean towels are at hand, 
and a fresh one is used for each patient. 

Where the light is poor, or patients are treated at night, a 
reflector may be needed. This can either be arranged on a 
bracket attached to the wall, or by a mirror for the head. 

The usually used Instruments are specula (Sims', Munde's, 
and bivalves), dressing forceps, sounds and probes, vaginal 
retractors, intra-uterine applicators, tenacula, and a pair of 
universal scissors. It is also convenient to have several 
flexible pessaries, a Wylie dilator, a box of Outerbridge's 
drains made of fourteen-carat gold, and a jar of tampons 
made ready for use. 




Fig. 101. Brewer's Speculum. 



APPENDIX. 



371 



Brewer's speculum (Fig. 101) is a bivalve instrument that 
is much used. It is an easy instrument to introduce, espe- 
cially where the vagina is small. It is small at the points of 
the blades, and enters the vagina without causing much in- 
convenience to the patient. It has been made of aluminium 
with slight increase in the price, and becomes one of the 
lightest instruments both for the patient and for the physi- 
cian to carry in his satchel. 

Graves' speculum (Fig. 102) is also a bivalve, but is much 
larger in the blade than the Brewer. It can be converted 
into a Sims speculum by reversing the blades. The extra 




Fig. 1(12. Graves' Specuh 



breadth of blade makes this a better instrument for large 
flabby vagina?, to secure a greater degree of separation of 
the vaginal walls. This instrument is much heavier than 
the one last described, and is also more complicated and 



372 MODERN GYNECOLOGY. 

more difficult to keep clean. It is also made of aluminium, 
when its weight ceases to be an objection. 

Sims' speculum has been described on page 39. For con- 
venience various modifications have been made. Dawson's 




Fig. 103. Dawson's Modification of Sims' Speculum. 

modified Sims' speculum has a hinge at the angle where the 
blades are fastened to the shaft. This makes it occupy less 
room in a satchel when folded (Fig. 103). 

Munde has modified Sims' speculum by adding a wide 
flange to one side to hold up the buttock. This instrument 




Fig. 104. Munde's Modified Sims' Speculum. 

is convenient when a Sims speculum is used without an 
assistant (Fig. 104). The self -retaining instrument of Cleve- 



APPENDIX. 373 

land is provided with a similar flange and is a more con- 
venient instrument. 

The most complete dressing forceps is shown in Figure 
105. The blades are so jointed together that their points 
separate with a spring action, being held together by a slid- 
ing catch, which is moved back and forth by the thumb held 




Fig. 105. Dressing Forceps. 

against the round projection on its upper side. The blades 
of this instrument should be very narrow and thin at their 
points and perfectly smooth on their faces. They are occa- 
sionally made with corrugations on their inner side, but 
should not be ; the grip of the blades should be sufficient to 
hold bits of cotton or a sponge without any roughening of 
the blades, and for the introduction of tampons the corru- 
gations are a disadvantage because they make it more dif- 
ficult to remove the instrument from the cotton after it 
has been introduced. When bunches of cotton are used to 
cleanse the vagina it is difficult to throw them loose from 
the forceps when the blades are roughened. It is very in- 
convenient to use both hands to remove these when making 
applications, as a tenaculum or other instrument may re- 
quire the other hand. Bozeman's dressing forceps (Fig. 33) 
are also needed. They have a double curve, and open at a 
joint in the middle like a pair of shears. They should be 
corrugated at the ends of each blade for about two inches, 
and the face of each blade should have a groove facing its 



374 MODERN GYNECOLOGY. 

fellow. These instruments can be used to introduce tents, 
and also to grasp small pieces of cotton in mopping out the 
interior of the uterus when the cervix has been dilated or is 
patulous. They can also be of use in removing larger pieces 
of retained placenta or fetal remains that have been de- 
tached by the curette. 

The remaining instruments of importance have already 
been mentioned in the preceding pages, and illustrations of 
them are there given. The points of importance in their 
selection are also given in the text. 



INDEX 



Abortion causing Metrorrhagia, 

132. 
Abscess, Pelvic, 308. 
Amenorrhoea, 61. 
Acquired, 69. 
Anaemia, 76. 
Castration, 83. 
Hyper-involution, 82. 
Menopause, 84. 
Plethora, 80. 
Pregnancy, 70. 
Wasting Diseases, 70. 
Primitive, 61. 
Anaemia, 61. 
Atresia, 62. 

Impaired Development, 62. 
Anaemia, 63. 

Amenorrhcea from, 63, 76. 
Treatment of, 77. 
Anteflexion, 233. 
Acquired, 235. 
Classification of, 239. 
Congenital, 233. 
Operations for Irreducible, 257. 
Anteversion, 229. 
Causes, 230. 
Pessaries, 232. 
Appendix, 363. 

Bartholinian Ducts, 153. 
Bartholinian Glands, 153. 
Bed-pan, 102. 



Bimanual Examinations, 32. 
Breasts, the, in Pregnancy, 75. 

Cabinet, the, 364. 
Carcinoma, 340. 

Of Cervix, 343. 

Of External Genitals, 341. 
Cervical Metritis, 200. 

Cysts with, 202. 

Erosion with, 201. 

Eversion with, 203. 

Hypertrophy with, 204. 

Laceration with, 204. 
Cervix, the, 183. 

Atresia of, 194. 

Atrophy of, 194. 

Divulsion of, 188. 

Hypertrophy of, 195. 

In Pregnancy, 73. 

Normal, 183. 

Stenosis, 183. 
Clitoris, the, 154. 

Adhesions of, 155. 
Constipation, 77. 

Cotton Tents for Uterine Hemor- 
rhage, 120. 
Curettement for Metrorrhagia, 144. 
Cystitis in the Female, 162. 

Digital Examination, 26. 
In Knee-chest Position, 35. 
In Sims' Position, 35, 



377 



378 



INDEX. 



Dilatation of the Cervix, 135. 
Displacements of the Uterus, 227, 

279. 
Divnlsion, Rapid, 140. 
Divulsors, 141. 

Dorsal-recumbent Position, 21. 
Douches, 97. 

Hemorrhage relieved by, 123. 

Position for, 100. 

Time for, 105. 

Vaginitis treated by, 180. 
Drains, Uterine, 191, 255. 
Dysmenorrhea, 54. 

Causes, 54, 237. 

Treatment, 56. 

Varieties, 54. 

Electricity for 

Fibroma, 336. 

Metritis, 221. 
Eneuresis in Young Children, 160. 
Eruptions, Uterine, 57. 

After Castration, 58. 
Examinations, 17. 

Bimanual, 32. 

Digital, 26. 

External, 24. 

Fingers for, 29. 

Oral, 17. 

Per Rectum, 30. 

Physical, 19. 

Single Women, 36. 

Through Bivalve Speculum, 37. 

Through Sims' Speculum, 39. 

Through the Bladder and Ure- 
thra, 35. 
Exploration of the Uterus, 134. 
External Genitalia, the, 24. 

Fetal Remains, Removal of, 143. 
Fibroma, 327. 
Abdominal, 332, 



Curettement for, 337. 
Electricity for, 336. 
Operations for, 338. 
Uterine, 327. 

Haematocele, Pelvic, 352. 

Extra-peritoneal, 354. 

Intra-peritoneal, 352. 
Hand, Positions of, 27. 
Hegar's Sign of Pregnancy, 74. 
Hemorrhage, Uterine, 114. 

Control of, 118. 

Cotton Tents for, 120. 

Drugs for, 124. 

From Leech Bites, 112. 

Hot Douches for, 123. 

Ice for, 124. 

Intra-uterine Packing for, 122. 

Tampons for, 118. 
Hymen, the, in Pregnancy, 72. 

Imperforate, 166. 

Ice for Uterine Hemorrhage, 124. 

Impaired Development, 62. 

Instruments for Office Work, 370. 

Interval between Periods, 50. 

Intra-uterine Applications for Me- 
tritis, 218. 

Intra-uterine Injections for Metri- 
tis, 220. 

Intra-uterine Packing for Hemor- 
rhage, 122. 

Inversion of the Uterus, 283. 

Jars, the, for Office Solutions, 366. 

Laminaria Tents, 136. 
Leeches, 109. 

Artificial, 112. 

Hemorrhage from, 112, 
Lubricants, 369, 



INDEX. 



379 



Massage, Pelvic, 270. 
Meatus Urinarius, 157. 

Artificial, 159. 
Menopause, the, 84. 

Fibromata at, 88. 

Malignant Growths at, 89. 

Xervous Symptoms, 90. 
Menorrhagia, 114, 115. 
Menstrual Abnormalities, 52. 
Menstrual Blood, Source of, 49. 
Menstrual Flow : 

Amount of, 50. 

Duration, 50. 
Menstruation, 48. 

Scanty, 92. 

Vicarious, 59. 
Metritis, 197. 

Cervical, 200. 

Gonorrhceal, 197. 

Pseudo, 206. 

Puerperal, 198. 

Results of, 199. 

Single Women with, 199. 

Treatment of, 213. 
Metrorrhagia, 114, 130. 
Mollites Uteri, 278. 

Xeuroses, Uterine, 57. 

Ovaries : 

Congestion of, 313. 

Diseases of, 313. 

Tumors of, 323. 
Ovaritis, 316. 

Acute, 317. 

Chronic, 320. 
Ovulation, 49. 

Pelvic Abscess, 308. 
Pelvic Peritoneum, the, 300. 
Pelvic Peritonitis, 300, 
Acute, 304, 



Chronic, 309. 
Peri-salpingitis, 298. 
Personal History, 18. 
Pessaries for 

Anteflexion, 253. 

Anteversion, 232. 

Introduction of, 275. 

Retroflexion, 270. 

Retroversion, 261. 
Placental Remains, 143. 
Positions, 21. 

Dorsal-recumbent, 21. 

Genu-pectoral, 23. 

Sims', 22. 
Pregnancy, 70. 

Breasts in, 75. 

Cervix in, 73. 

Examination for, 71. 

Hegar's Sign of, 74. 

Hymen in, 72. 

Uterus in, 73. 

Vulva in, 71. 
Prolapse : 

Genital, 280. 

Urethral, 157. 
Puberty, 48. 

Age of, 50. 

Signs of, 48. 
Puncture of the Cervix, 108. 
Pyo-salpinx, 298. 

Rest for Menorrhagia, 128. 
Retro-deviations, 258. 
Retroflexion, 262. 

Operations for, 277. 
Retroversions, 259. 

Salpingitis, 292. 

Acute, 293. 

Chronic, 294. 
Scarification, 109. 
Sedatives for Menorrhagia, 127- 



380 



INDEX. 



Siphon, the, 103. 
Solutions, the, 366. 
Sounds, 243. 
Specula, 371. 

Self-retaining, 42. 
Cleveland's, 43. 
Sponge Tents, 135. 
Syringes, 98. 

Table, the, 20, 364. 

Tampons for Hemorrhage, 118. 

Tents : 

Cotton, 120. 

Dilatation of Cervix with, 135. 

Introduction of, 139. 

Laminaria, 136, 137. 

Sponge, 135, 136. 

Tupelo, 136, 138. 

Urethra, the, 157. 

Prolapse of, 157. 

Stricture of, 160. 
Urethritis, 161, 163. 
Urinary Meatus, 157. 
Uterine Deviations, 228. 



Uterine Displacements, 227. 
Uterine Drains, 191. 
Uterine Eruptions, 57. 
Uterine Massage, 270. 
Uterine Neuroses, 57. 
Uterine Reflexes, 210. 
Uterine Syndroma, 206. 

Vagina : 

Abnormalities, 166. 

Atresia of, 168. 

Diseases of, 164. 
Vaginismus, 172. 
Vaginitis, 174. 

Acute, Non-specific, 177. 

Chronic, 178. 

Follicular, 179. 

Gonorrhceal, 174. 
Vicarious Menstruation, 59. 
Vulva, Diseases of, 147. 
Vulva, the, in Pregnancy, 71. 
Vulvitis : 

Gonorrhoea^ 149. 

Small Children, 147. 

Treatment, 148, 152. 




THE INTERNATIONAL 

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PHOTOGRAPHIC ILLUSTRATIONS OF 

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Upwards of One Hundred Cases from Life. 

By GEORGE HENRY FOX, A.M., M.D., 

Clinical Professor of Skin Diseases, College of Physicians and Surgeons, New York ; Trot, of 
Diseases of the Skin, Post Graduate Medical School and Hospital, New York ; Physician 
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Surgical Handicraft. 

-A MANUAL- 

OF 

Surgical Manipulations, Minor Surgery, and 

other matters connected with the work of 

House Surgeons and Surgical Dressing. 

By WALTER PYE, F.R.C.S., 

Surgeon to St. Mary's Hospital and the Victoria Hospital for Sick Children , late 
Examiner in Surgery at the University of Glasgow. 

UPWARDS OF 300 ILLUSTRATIONS ON WOOD. 
FIRST AMERICAN EDITION, 

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EXCESSIVE 

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THEREFROM. 

BV 

JOSEPH W. HOWE, M.D., 

Late Professor of Clinical Surgery in Bellevue Hospital Medical College, 
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Second Edition Revised. 

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INSANITY. 

Its Classification, Diagnosis and Treatment; 

A Manual for Students and Practitioners of Medicine. 

BY 

E. C. SPITZKA, M. D., 

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HOW TO USE THE FORCEPS: 

WITH AN INTRODUCTORY ACCOUNT OF THE 

:f:e:m:^:il.:e pelyis, 

AND OF 

THE flECHANISM OF LABOR. 



HENRY G. LANDIS, A.M., M.D., 

Late Professor of Obstetrics and Diseases of Women and Children in Starling Medici. 

College, Columbus, O. 

Revised and Enlarged by CHARLE5 H. BUSHONG, M.D., 

Assistant Gynecologist to the Demilt Dispensary, New York, formerly attending Physician 

to the Northern Dispensary, and ass'stant to the Vanderbilt Clinic, 

College of Physicians and Surgeons, New York. 



The time was, and is within the memory of our seniors 
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